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Association between Multiple IV attempts and Perceived Pain levels in the Emergency Department
Abstract
Purpose:
Intravenous (IV) access is the most commonly performed procedure in the emergency department (ED). Patients with difficult venous access require multiple needlesticks (MNS) for successful IV cannulation and may experience increased pain with many attempts.
Objective:
To determine the association between number of IV attempts and overall pain experienced by the patient from IV placement.
Methods:
Cross-sectional observational study on consecutive patients undergoing IV placement with a 20-gauge IV in the upper extremity in an urban academic hospital. Exclusion criteria included refusal to participate or fully complete all survey questions. The total number of IV attempts and patient pain scores marked on a standardized visual analog scale was recorded. Mean pain scores of two groups, single needlestick (SNS) and MNS, were compared using Student's t-test.
Results:
A total of 760 patients were approached, of whom 31 were excluded, leaving 729 patients in the analysis; 556 with SNS (76%) and 173 with MNS (24%). The mean pain score (95% CI) was 51 mm (46-55 mm) for the MNS group and 25 mm (23-28 mm) for the SNS group, p<0.001. Compared to patients who underwent one IV attempt, patients with two and three attempts had an average 19 mm and 33 mm increase in pain scores, respectively, with the highest average pain associated with five attempts. A total of 58% of MNS patients rated IV placement as the most painful experience while in the ED.
Conclusions:
Patients experience increased pain in association with multiple IV attempts.
... [1][2][3] Failed attempts to gain intravenous (IV) access can also compromise the patient's trust and confidence in the nursing staff. 1 IV peripheral access is considered difficult when there is more than one insertion attempt. [4][5][6] Variables such as age, [7][8][9] skin color, 7 obesity, 6-10 patients' clinical complexity, 8 history of difficult intravenous access (DIVA), [8][9][10] chemotherapy use, 7-9 cannula size, 9,10 skill of the clinician, 8 and the number of IV attempts [8][9][10] can influence the success of IV access. ...
... 14,15 According to the literature, females are more prone to DIVA occurrence, with a reported prevalence three times greater in women than in men. 4,5 The results of this investigation showed 39.2% DIVA prevalence in women and 29.5% in men, and the risk increased by 1.54 for females (P = 0.132). Researchers of another study reported that IV access performed on women required more time and was associated with a greater prevalence of DIVA (OR = 1.72). ...
... Researchers of another study reported that IV access performed on women required more time and was associated with a greater prevalence of DIVA (OR = 1.72). 5 In our study, the participants' age ranged from 18 to 92 years. Population aging has had a direct impact on the profile of patients undergoing hospitalization due to increased noncommunicable chronic diseases. ...
... [1][2][3] Failed attempts to gain intravenous (IV) access can also compromise the patient's trust and confidence in the nursing staff. 1 IV peripheral access is considered difficult when there is more than one insertion attempt. [4][5][6] Variables such as age, [7][8][9] skin color, 7 obesity, 6-10 patients' clinical complexity, 8 history of difficult intravenous access (DIVA), [8][9][10] chemotherapy use, 7-9 cannula size, 9,10 skill of the clinician, 8 and the number of IV attempts [8][9][10] can influence the success of IV access. ...
... 14,15 According to the literature, females are more prone to DIVA occurrence, with a reported prevalence three times greater in women than in men. 4,5 The results of this investigation showed 39.2% DIVA prevalence in women and 29.5% in men, and the risk increased by 1.54 for females (P = 0.132). Researchers of another study reported that IV access performed on women required more time and was associated with a greater prevalence of DIVA (OR = 1.72). ...
... Researchers of another study reported that IV access performed on women required more time and was associated with a greater prevalence of DIVA (OR = 1.72). 5 In our study, the participants' age ranged from 18 to 92 years. Population aging has had a direct impact on the profile of patients undergoing hospitalization due to increased noncommunicable chronic diseases. ...
Objective
To determine the prevalence of difficult venous access in adult patients admitted to a surgical unit.
Method
This observational prospective cohort study included 235 patients from a Brazilian hospital. Clinical data were collected by direct observation and analyzed by descriptive, inferential statistics, and multiple binomial logistic regressions. Odds ratios were also calculated.
Results
Most of the patients (66.4%) were men and self-reported as white (59.2%). The prevalence of difficult intravenous access was 32.8%. Predictors of peripheral intravenous cannula insertion failure were history of difficult intravenous access and nonvisibility of the vein.
Conclusion
History of difficult intravenous access and a nonvisible venous network were significant predictors of peripheral cannula insertion failure in adults undergoing clinical surgery. The prevalence of difficult intravenous access was 32.8%.
... Patients who underwent one IV attempt experienced an increase of only 25 mm VAS. 11 Multiple insertions may also delay treatment for 120 minutes as much 5% of the time and for 15 minutes as much 23%. 12 This is work time that nurses lose, it affects client satisfaction, and it raises the cost of treatment. ...
... This is compared to patients who underwent one insertion, which caused 25 mm VAS. 11 Donia and Tolba had results similar to those of this study. They explained that infants who underwent painful procedures had an average pain score of 5 points. ...
Low-Birth-Weight (LBW) infants have very small veins, and there is a risk of needing multiple insertions to establish peripheral intravenous access. This study aimed to examine the impacts of multiple insertions during peripheral intravenous access in LBW infants. This cross-sectional study involved 216 respondents. Data were analyzed with the Spearman correlation. The results showed a significant relationship (p<α) between multiple insertions to establish peripheral intravenous access to LBW infants with increased pain, heart rate, respiratory rate, duration of crying, delayed treatment, duration of insertion, and high cost of care (p<0.001; r=0.358-0.836). Meanwhile, multiple insertions might decrease oxygen saturation and body temperature (p<0.001; r=0.358). In this study, multiple insertions were correlated with several negative impacts on the physiological function and discomfort of LBW infants. The study also highlights the effect on time of treatment precision and cost effectiveness. Recommendation: It is necessary to develop preventive measures to reduce the impact of multiple insertions to establish peripheral intravenous access in LBW infants.
... [2][3][4][5][6] Studies from the emergency room and perioperative settings reveal that DIVA occurs in approximately 5% of children, leading to poorer patient experience, delays in care, and increased cost. 3,[6][7][8][9] Clinical care pathways directing earlier use of ultrasound can reduce the number of PIV attempts, yielding an improved patient experience. [10][11][12][13][14] Also, using ultrasound in DIVA can reduce the need for central venous catheter placement, mitigating risks attendant to the placement and use of those catheters (eg, pneumothorax and line infection). ...
... [11][12][13][14]16,22 Ultrasound guidance for vascular access in emergency departments is increasingly common. 7,9,12,13,[22][23][24] A randomized controlled trial of 167 children presenting to the emergency room with DIVA, comparing ultrasound-guided PIV to palpation methods, found improved first-pass success, fewer attempts, and faster readiness. 25 These findings may not hold in children without DIVA presenting to the emergency department. ...
Factors predicting difficult peripheral intravenous (PIV) catheter placement in children are known. Ultrasound guidance can decrease the number of attempts required for difficult PIV placement. However, the uptake of this technique among attending anesthesiologists at our institution remained low. This study aimed to reduce the incidence of PIV placement requiring greater than 3 attempts and reduce time to PIV placement by providing training in ultrasound guidance.
Methods:
We implemented an evidence-based difficult IV algorithm and ultrasound-guided PIV placement training for attending pediatric anesthesiologists at a tertiary academic pediatric institution. The algorithm outlined risk factors for difficult IV access, established a goal of 3 or fewer attempts, and recommended early ultrasound use after 1 unanticipated attempt and the first attempt for anticipated difficult IV. Group sessions, including instruction and simulated practice, preceded a period of individual training in the operating room using a punch card to monitor each trainee's progress while also serving to motivate continued engagement.
Results:
We performed a cross-sectional analysis of consecutive cases from December 1, 2015, to September 30, 2019, comparing a 22-month baseline period (n = 12,581) with the training period (n = 6,725) and the following year (n = 6,557). Cases requiring more than 3 attempts decreased from 4.0% to 2.7% overall and from 10% to 6.2% among patients 24 months or less of age. The time required to establish PIV access was unchanged. Factors associated with increased attempts were identified.
Conclusions:
Implementing a difficult IV algorithm and training among attending pediatric anesthesiologists in ultrasound-guided PIV placement reduced attempts but not the time required to establish PIV access.
... In addition, the term 'difficult peripheral intravenous cannulation' (DPIVC) 10 has been suggested to differentiate peripheral from central catheterization. DPIVC causes pain and distress to patients, 11 can lead to adverse events including diagnostic delays 12 and result in catheter-related complications such as infiltration, vein collapse or nerve damage. 13À15 In addition, DPIVC can also be challenging or stressful for health professionals involved in intravenous therapy. ...
... 33 This tool assigns a score when a study meets one or several conditions that add validity or methodological rigor. Additionally, the STROBE statement check list (version for all observational methods) 34 Full-text arƟcles excluded, with reasons (n =12) 11 Not meeƟng inclusion criteria 1 extended report of previously included data ...
Peripheral venous catheterization is a common technique in hospitals which is not always successful, resulting in multiple punctures and degradation of the vessels. This scenario, which we have termed ‘difficult peripheral venous access’, is associated to delays in care, obtention of samples or diagnosis, as well as a higher use of central catheters.
This study intends to identify risk factors associated to the incidence of ‘difficult peripheral venous access’ in adults at hospital.
We designed a systematic review of published studies (protocol PROSPERO 2018 CRD42018089160). We conducted structured electronic searches using key words and specific vocabulary, as well as directed searches in several databases. After validity analysis, we selected 7 studies with observational methodology.
We found great variability in the definition of ‘difficult peripheral venous access’ and in the variables proposed as risk factors. Statistically significant factors through studies include demographic and anthropometric variables (gender, Body Mass Index), as well as medical and health conditions (diabetes, renal insufficiency, parenteral drug abuse, cancer chemotherapy), together with variables related to the vein or vascular access (vein visibility and palpability, vessel diameter, previous history of difficulty). Some studies have also considered variables related to the professional performing the technique.
Meta-analyses were carried out for gender and obesity as potential risk factors. Only obesity appeared as a statistically significant risk factor with OR of 1.48; 95% CI (1.03 to 1.93; p = 0.016). Methodological heterogeneity prevented the development of further meta-analyses.
It is essential to design future studies with diverse hospital populations, in which a wide selection of potential risk factors can be studied in a unique analysis. Our work identifies the most relevant variables that should be included in those studies.
... It has been found within an emergency department patients reported an increase of pain with each failed cannulation attempt when multiple attempts had been made; stating that cannulation is the most painful aspect of their treatment. 10 It has been described that the effect of repeated failed attempts of cannulation can lead to loss of an access site or it being compromised and the risk of subsequent phlebitis and failure is increased. 11 Researchers have 3 found that staff reported attempting DiVA multiple times ending up placing the PIVC in a small vein which had inadequate blood flow which causes the cannula to fail just a few hours later. ...
... Our findings contribute original, novel and apposite data on intravenous access. The chi-square statistics for vein visibility for left dorsal hands is 10.1403 with p-value of 0.006282. ...
Vascular access for venepuncture and peripheral intravenous cannulation is a common procedure within health care. First-attempt cannula insertion success rate has been found to be lower in some patient groups. Multiple unsuccessful cannulation attempts have negative impacts for both patients and practitioners. This article reports on research investigating the effectiveness of an innovative device called the Vacuderm-a single-use tourniquet with added manual vacuum pump-in increasing vein dimensions, temperature difference between vein and its surrounding and visual clarity through an additional effect of creating a vacuum on top of the tourniquet. A randomised crossover design was used in this study for looking at the vein visibility, dimensions and thermal behaviour using infrared thermography. Dorsal areas of both hands were assessed in a random crossover study of 20 healthy volunteers with and without the application of the Vacuderm. The results show significant increase in venous diameter and venous cross-sectional area with highly significant increase in vein clarity caused by using the Vacuderm, which creates a negative pressure for transient suction in addition to its vein occlusion effect.
... Furthermore, in some countries, including Denmark, many paramedics are not authorized to administer IV medication [41]. Studies outside of this Europe-focused literature search have also reported associations between IV access difficulties and increased on-scene time for ambulance crews, and consequent ED crowding as attention of HCPs is diverted [42][43][44]. ...
... Pain imposes a substantial burden on emergency care, as this is often the primary complaint of patients presenting to EDs [59]. We have identified a variety of limitations associated with many analgesics, including difficulties associated with IV administration necessary for some drugs and bulky equipment requirements for N 2 O, particularly in pre-hospital settings [34,43,44]. Other treatment-associated limitations identified include aversion to opioid analgesics due to perceptions associated with this class of agents, safety concerns, and regulatory barriers [14,41,53]. ...
Trauma pain represents a large proportion of admissions to emergency departments across Europe. There is currently an unmet need in the treatment of trauma pain extending throughout the patient journey in emergency settings. This review aims to explore these unmet needs and describe barriers to the delivery of effective analgesia for trauma pain in emergency settings. A comprehensive, qualitative review of the literature was conducted using a structured search strategy (Medline, Embase and Evidence Based Medicine Reviews) along with additional Internet-based sources to identify relevant human studies published in the prior 11 years (January 2006–December 2017). From a total of 4325 publications identified, 31 were selected for inclusion based on defined criteria. Numerous barriers to the effective treatment of trauma pain in emergency settings were identified, which may be broadly defined as arising from a lack of effective pain management pan-European and national guidelines, delayed or absent pain assessment, an aversion to opioid analgesia and a delay in the administration of analgesia. Several commonly used analgesics also present limitations in the treatment of trauma pain due to the routes of administration, adverse side effect profiles, pharmacokinetic properties and suitability for use in pre-hospital settings. These combined barriers lead to the inadequate and ineffective treatment of trauma pain for patients. An unmet need therefore exists for novel forms of analgesia, wider spread use of available analgesic agents which overcome some limitations associated with several treatment options, and the development of protocols for pain management which include patient assessment of pain.
Funding: Mundipharma International Ltd.
Electronic supplementary material
The online version of this article (10.1007/s40122-018-0101-1) contains supplementary material, which is available to authorized users.
... Multiple punctures provoke delays in care, in obtaining diagnosis or in initiating treatment. [2][3][4] Furthermore, it generates stress, heightens perceptions of pain 5 and reduces satisfaction, both among patients and among the professionals performing the technique. 4 6 In addition, multiple punctures may be associated with a progressive deterioration of the vascular tree, termed 'vascular exhaustion', which makes vascular access even more difficult in successive contacts with the patient. ...
... The minimum sample size was calculated taking as a reference the risk factor 'diabetes' from the study of A&E patients conducted by Fields et al in 2014. 5 Assuming an alpha risk of 0.05 and a beta risk of 0.2 in a bilateral test, we calculated that 87 cases and 261 controls would be required to detect a minimum OR of 2.1, assuming a rate of exposure of 0.5 in the control group. In this consideration, the Poisson method was used. ...
Introduction
Patients with difficult venous access experience undesirable effects during healthcare, such as delayed diagnosis and initiation of treatment, stress and pain related to the technique and reduced satisfaction. This study aims to identify risk factors with which to model the appearance of difficulty in achieving peripheral venous puncture in hospital treatment.
Methods and analysis
Case–control study. We will include adult patients requiring peripheral venous cannulation in eight public hospitals, excluding those in emergency situations and women in childbirth or during puerperium. The nurse who performs the technique will record in an anonymised register variables related to the intervention. Subsequently, a researcher will extract the health variables from the patient’s medical history. Patients who present one of the following conditions will be assigned to the case group: two or more failed punctures, need for puncture support, need for central access after failure to achieve peripheral access, or decision to reject the technique. The control group will be obtained from records of patients who do not meet the above conditions. It has been stated a minimum sample size of 2070 patients, 207 cases and 1863 controls. A descriptive analysis will be made of the distribution of the phenomenon. The variables hypothesised to be risk factors for the appearance of difficult venous cannulation will be studied using a logistic regression model.
Ethics and dissemination
The study was funded in January 2017 and obtained ethical approval from the Research Ethics Committee of the Balearic Islands. Informed consent will be obtained prior to data collection. Results will be published in a peer-reviewed scientific journal.
... Risk factors and the patient medical conditions which may result in difficult vein access include the patient's age, experience of the person performing the procedure, the size of the cannula and the site of insertion (Chinnock, et al., 2007;Sebbane, et al., 2013;Heinrichs, et al., 2013). In addition, there are some characteristic groups of patients with whom establishing a peripheral venous line is more difficult: obese patients, patients with peripheral oedema, patients undergoing chemotherapy, intravenous drug abusers, severely dehydrated patients (Gregg, et al., 2010;Fields, et al., 2014), dark skinned patients (Aulagnier, et al., 2014), as well as children and the elderly (Walsh, 2008). Lack of skill, inept nurses or difficult intravenous access contribute to the need for repeated attempts of insertion (Walsh, 2008). ...
... Obstajajo tudi značilne skupine pacientov, pri katerih je vzpostavljanje periferne venske poti oteženo: pacienti s prekomerno telesno težo ali s perifernimi edemi, pacienti na kemoterapiji, i.v. uporabnikih drog, močno dehidrirani pacienti (Gregg, et al., 2010;Fields, et al., 2014), pacienti temnejše polti (Aulagnier, et al., 2014), otroci in starostniki (Walsh, 2008). Pomanjkljive veščine, nespretnost medicinskih sester ali težak i.v. ...
Introduction: Biomedical devices are tools used for locating invisible and impalpable peripheral veins. The purpose of this article is to give a systematic review and analysis of existing studies on the available biomedical devices used for locating peripheral veins and on their effectiveness in clinical practice.
Methods: Databases CINAHL, Medline and ScienceDirect were used for the literature review and analysis. The search was performed with the following key words in English: devices, visualization, technology, cannulation, vein, nursing care, with Boolean operators 'AND' and 'OR'. The analysis included randomized and experimental clinical studies published in the English language in the period from 2000 to August 2016. From a total of 1,020 retrieved studies, 17 were included in the detailed analysis.
Results: The results of the analysis have shown that the success rate of the first attempt of intravenous cannulation using biomedical devices in more than half of the studies was not significantly higher than when the process was performed using the conventional method. The success of the first attempt of intravenous cannulation mostly depends on the experience and skills of nurses. Biomedical devices are more helpful for novice nurses who do not perform cannulation on a daily basis, for beginners and nursing students.
Discussion and conclusions: Based on research, we cannot affirm that biomedical devices significantly contribute to easier peripheral venous cannulation. Further research is required to validate the advantages of such an approach. However, this is limited due to the affordability issues of such biomedical devices.
... It has been found within an emergency department patients reported an increase of pain with each failed cannulation attempt when multiple attempts had been made; stating that cannulation is the most painful aspect of their treatment. 10 It has been described that the effect of repeated failed attempts of cannulation can lead to loss of an access site or it being compromised and the risk of subsequent phlebitis and failure is increased. 11 Researchers have 3 found that staff reported attempting DiVA multiple times ending up placing the PIVC in a small vein which had inadequate blood flow which causes the cannula to fail just a few hours later. ...
... Our findings contribute original, novel and apposite data on intravenous access. The chi-square statistics for vein visibility for left dorsal hands is 10.1403 with p-value of 0.006282. ...
Intravenous cannulation is the process of inserting a cannula into a vein to administrate medication, fluids, or to take blood samples. The process of identification and of locating veins plays an important role during the intravenous cannulation procedure to reduce health care costs and the suffering of patients. This paper compares the three technologies used to assess their suitability and capability for the detection of veins to support the cannulation process. Three types of cameras are used in this study; a visual, an infrared, and a near infrared. The collected images, 103 in total, from the three technologies have been analyzed using a wide range of image processing techniques and compared with identification templates to evaluate the performance of each technology. The results show that the near infrared technology supported by suitable LED illumination is the most effective for the visualization of veins. However, infrared thermography is found to be successful when followed by a cold stimulation.
... Along with this, the medical practitioner's skill and experience also have a significant impact on the procedure [5]. With the prevalence of venipuncture, the issues that stem from difficult intravenous access such as patient distress and diagnostic delays cannot be understated both in terms of the number of occurrences or severity of complications [6,7]. ...
Attaining venous access is a common requirement for clinical care worldwide, with a non-negligible portion of cases often being categorized as ‘difficult intravenous access’. Such complications result in far-reaching consequences affecting clinicians and patients alike. We propose a mixed-reality-based vein detection and visual guidance system that provides several key advantages, including a wider field of view, flexible operating distance, and hands-free, intuitive usage compared to existing solutions. A semi-supervised learning approach was used in model training to circumvent dataset availability limitations. Quantitative evaluation showed that the semi-supervised approach improved vein detection performance and temporal consistency. The system was also implemented and trialed in a clinical setting to assess real-world usability. Initial, preliminary assessment of HoloVein by medical professionals in a clinical setting showed improvements in detection quality using the semi-supervised approach over the baseline model. This result was deemed to be promising from a clinical perspective and could set the stage for more widespread mixed-reality venipuncture guidance tools in the future.
... This result is compared with a finding of previous research in which patients' physical and psychological comfort influenced nursing staff preference (10). Utilization of PIVC for blood sampling would enhance patients' satisfaction as the successive attempts of blood collection by the standard venipuncture is significantly associated with higher pain perception scores (23). In addition, it permits venous access site preservation, particularly for those with poor and limited access (24). ...
Background:
Blood tests are usually obtained by venipuncture which is an insertion of a needle into a vein. Since blood collection is frequently ordered, it contributes to the increased workload on healthcare professionals. Thus, utilization of previously inserted peripheral intravenous lines for blood collection is proposed to decrease the work burden.
Objective:
The aim of the study was to make assessment of the awareness and practice of emergency medicine and intensive care unit staff regarding blood sampling via pre-existing peripheral line.
Methods:
This is a cross-sectional study used a web-based and self-administered questionnaire. It distributed among emergency department and intensive care unit staff between November 2021 and February 2022.
Results:
A total of 95 healthcare providers participated in the study. Most respondents were nurses (n=49, 51.5%) with 58.5% assigned to the intensive care unit. The overall mean awareness score was 1.74 out of 4 points with standard deviation of 1.29. Poor awareness was found among (n=65, 68.4%) and the remaining (n=30, 31.6%) had good awareness. Positive significant association has been observed between the level of awareness and practice (p=0.015). no significant difference was found between the emergency department and intensive care unit staff in terms of awareness level and practice.
Conclusion:
Findings from the current study showed variation in participants' views, hence, nurses and other health care providers are left to use their personal preferences in deciding patient care. This highlights the need for establishing institutional policies regarding blood sampling via a pre-existing peripheral intravenous line.
... Attualmente in caso di DVA si procede con l' esecuzione di ripetuti tentativi di incannulamento, coinvolgendo membri del team più esperti o ricorrendo al medico anestesista reperibile (12) il quale dopo aver tentato ulteriormente di reperire un accesso per via periferica procederà con il posizionamento di un CVC ad inserzione centrale (14). Questo approccio espone l'assistito con accesso vascolare difficile ad un rischio maggiore di insorgenza di infezioni catetere-correlate (1), ad un incremento della percezione del dolore e del discomfort (11,19,20) e progressivamente ad deterioramento progressivo del reticolo endovenoso per traumi vasali da ripetute venipunture. Questo quadro di "vascular exhaustation" renderà più complicato il reperimento di ulteriori accessi venosi (17) e determinerà un fallimento precoce dei VAD posizionati (15). ...
INTRODUZIONE: L’ accesso vascolare difficile si manifesta nel 30% degli assistiti che necessitano un accesso vascolare. E’ una condizione clinica che determina l’esecuzione di molteplici tentativi di incannulamento della vena. La gestione è affidata ad un team infermieristico dedicato con competenze avanzate nell’impianto di cateteri venosi periferici (CVP), PICC e Midline tramite tecnica ad ultrasuoni. OBIETTIVO:Effettuare un’analisi della letteratura indagando outcome e benefici della gestione di questi assistiti da parte di un team infermieristico con competenze avanzate negli accessi vascolari. METODI: Sono state consultate le banche dati PubMed, CINAHL, EMBASE, Cochrane Library, ILISI e Web of Science ed i siti ufficiali dell’ INS e del GAVeCeLT. RISULTATI: Sette studi sono stati inclusi. Il team è composto in media da 15 infermieri e 4 medici specialisti. Emerge un tasso di successo della procedura al primo tentativo dell’88-100% ed una riduzione del 90% e 70 % dei tassi di CLABSI e infezioni catetere-correlate. In media il 44.1% dei device sono stati rimossi per termine del trattamento. L’ attesa del device idoneo si è ridotta dell’ 80%. Il tasso medio di soddisfazione è risultato dell’ 88.23% (score medio registrato 8.56/10) ed una media di 2.85/10 per il dolore percepito. Le aziende hanno riportato una riduzione media di 261.358,27 euro/anno sulle spese aziendali. CONCLUSIONI: Un team dedicato per gli accessi vascolari difficili rappresenta una risorsa fondamentale per l’ erogazione di cure di qualità grazie ad una gestione tempestiva, una riduzione dei tassi di complicazioni, un’ ottimizzazione del timing assistenziale e delle spese aziendali.
... 12 In the presence of DVA, patients are exposed to multiple interventions, resulting in increased pain levels. 8,14 Thus, being successful in the first attempt is important in patients undergoing PIVC. As an alternative to the standard method, it is desired to increase the success rates by using technological devices, such as ultrasound and NIR. ...
Objectives
Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA.
Methods
This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims.
Results
This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods.
Conclusion
It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.
... 29,30,32 PIVC failures can lead to increased costs, delays in care, complications from device failure, such as infiltration, phlebitis, or thrombosis, and often expose the patient to additional pain and trauma from recurrent PIVC insertion attempts. [33][34][35][36][37] There are also increasing concerns that repeated puncture attempts and recurring device failure precipitate venous depletion, and undermines overall vessel health. 1,38 These reports have led some authors to conclude that USGPIVs may only be appropriate for shortterm infusions or as a temporary bridge until more definitive vascular access can be established. ...
Problem
Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures.
Aims
The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses.
Methods
The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure.
Results
A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan–Meier survival probabilities than PIVs ( p < 0.001).
Conclusions
The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes.
... Although venous puncture is generally considered to generate only low-intensity pain, our study confirms previous research findings that there is a clinically significant difference between the sensation of pain described by patients with DPIVC and that of patients who do not present this difficulty [29,30]. Situations of difficult access, as well as provoking multiple punctures, often result in cannulation manoeuvres that generate more tissue damage, with possible adverse effects for the patient, thus degrading the quality of healthcare and the user's satisfaction [3,31,32]. ...
Background:
Difficult peripheral intravenous cannulation (DPIVC) is associated with serious complications related to vascular access. These complications might be avoided if the risk factors were identified previously, enabling the detection of potentially difficult situations at an early stage. The aim of this study is to consider these risk factors, to determine the influence of the hospital setting, to examine the association between DPIVC and the different techniques of catheter insertion and to analyse the importance of the clinician's experience in this context.
Methods:
Case-control study following a previously published protocol, conducted in 48 units of eight public hospitals in Spain. Adult patients requiring a peripheral intravenous cannula were prospectively included in the study population during their hospital stay. Over a period of 11 months, for consecutive eligible patients, nurses in each participating unit recorded data on their assessment of the vascular access performed and the technique used. Variables related to these medical personnel were also recorded. One of the researchers reviewed the patients' clinical history to compile the relevant health variables and to characterise the healthcare process. The statistical analysis included association tests among the main study variables. The risk factors were analysed using bivariate logistic regression. The variables found to be statistically significant were included in a multivariate logistic regression model incorporating each of the healthcare environments identified.
Results:
The study population was composed of 2662 patients, of whom 221 (8.3%) presented with DPIVC. A previous history of difficulty, the presence of non-palpable veins, acute upper limb alterations and punctures in the ante-cubital fossa were found to be independent risk factors for DPIVC. Differences were found in the frequency of occurrence of DPIVC and in some risk factors, according to the healthcare context. The variables related to the characteristics of the hospital personnel did not influence the study event.
Conclusion:
The present study identifies four independent risk factors for DPIVC that can be incorporated into algorithms aimed at preventing its occurrence and facilitating the referral of patients to vascular access specialist teams.
... Apenas um estudo apresentava abordagem prospectiva e randomizado, sendo classificado como nível de evidência 2B, os demais foram todos observacionais. Ver Quanto aos fatores demográficos e clínicos foram indicados: sexo 8,9 , cor da pele 3 , idade 3,8,9,16 , obesidade 9,17,18 ou desnutrição 6,18 , higiene do paciente 19 , complexidade clínica 6 , desidratação 3,18 , visibilidade e/ou palpabilidade da veia 3,9,18,20 , doenças crônicas 5,8,18 e histórico de PVPD 3,9,20 , entre outras condições. ...
Objective
to identify factors that pose difficulties in peripheral venipuncture in adults.
Method
in this integrative literature review, with no time cutoff, search of the PubMed, LILACS, CINAHL, SciELO, Web of Science, and Scopus databases, in January 2018, yielded 12 articles for inclusion. These were examined for year, country of publication, associated factors, and level of evidence.
Results
publications were found from 2003 to 2017. The prevalence of difficult peripheral venipuncture ranged from 17% to 59.3%. The most frequent factors making for difficult puncture were: demographic (gender, age), clinical (comorbidities, nutritional status, visibility and palpability of the venous network), device-related (caliber and model), and professional skill.
Conclusion
difficulty in puncture varies with complexity of care. Demographic-, clinical-, device- and professional skill-related factors should be considered.
... A recent systematic scoping review on improving first-time insertion success (FTIS) decision approaches identified the lack of a robust clinical decision tool to guide clinicians inserting PIVCs in adults. 2 Despite the clinical utility and ubiquity of PIVC insertion in EDs, obtaining PIVC FTIS is a clinical problem which appears to be largely ignored. It is important to highlight that PIVC insertion failure has been described as painful, 3 with repeated punctures likely increasing the risk of infection, 4 5 all of which can negatively strengths and limitations of this study ► The study used researcher observations rather than self-report. ► Validated data on patient, clinician, product and technology factors were obtained to assess any relationship with FTIS. ...
Objectives
This study aimed to identify the incidence of and factors associated with peripheral intravenous catheter/cannula (PIVC) first time insertion success (FTIS) in the emergency department (ED).
Design
Prospective cohort study.
Setting
Two tertiary EDs in Western Australia.
Participants
879 ED patients.
Primary outcome
To identify factors affecting FTIS using univariate and multivariate logistic regression modelling. We created four models: patient factors only; clinician factors only; products and technology factors only and all factors model . We assessed each model’s performance using area under the receiver operating characteristic curve.
Results
A total of 1201 PIVCs were inserted in 879 patients. The mean age was 60.3 (SD 22) years with slightly more females (52%). The FTIS rate was 73%, with 128 (15%) requiring a second attempt and 83 (9%) requiring three or more attempts. A small percentage (3%) had no recorded number of subsequent attempts. FTIS was related to the following patient factors: age (for a 1-year increase in age: OR 0.99, 95% CI 0.983 to 0.998; p=0.0097); and target vein palpability: (always palpable vs never palpable: OR 3.53 95% CI 1.64 to 7.60; only palpable with tourniquet vs never palpable: OR 2.20, 95% CI 1.06 to 4.57; p=0.0014). Clinician factors related to FTIS include: clinicians with greater confidence (p<0.0001) and insertion experience (301–1000 vs <301: OR 1.54, 95% CI 1.02 to 2.34; >1000 vs <301: OR 2.07, 95% CI 1.41 to 3.04; p=0.0011). The final all factors model combining patient factors; clinician factors and product and technology factors has greater discriminative ability than specific factors models. It has a sensitivity of 74.26%, specificity of 57.69%, positive predictive value of 82.87% and negative predictive value of 44.85%.
Conclusion
A clinical decision, matching patients who have no palpable veins and are older, with clinicians with greater confidence and experience, will likely improve FTIS.
Trialregistration number
ANZCTRN12615000588594; Results.
... Despite the limited data available for this meta-analysis, the results presented here further support the efficacy of SCIg for the maintenance of muscle strength in auto-immune neurodegenerative diseases and myopathies. As these neuromuscular diseases are chronic conditions, subcutaneous administration provides an important therapeutic alternative for those whom repeated intravenous access may lead to vascular exhaustion [64,65] and increased treatment related pain and discomfort [66]. Such complaints may explain the patient preference for SCIg observed in our meta-analysis, or the results of earlier studies in primary antibody deficiency cohorts [32,33]. ...
We reviewed the efficacy of SCIg administration in terms of muscle strength maintenance and patient satisfaction comparing with IVIg in the treatment of auto-immune neuromuscular diseases. A systematic review was conducted, and identified studies from databases (PUBMED, EMBASE, EBSCO, Web of Science and Google Scholar) which were analyzed. The methodological quality of the selected publications was evaluated using the Newcastle-Ottawa Scale. Data were extracted from a total of 11 studies Fixed and random-effect model meta-analyses were performed. For the maintenance of muscle strength, Overall Neuropathy Limitations Scale (ONLS) data from 100 patients diagnosed with multifocal mononeuropathy (MMN) or chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) were pooled together. Switching to subcutaneous immunoglobulin administration led to a significant improvement (fixed effects model, p = 0.002). In data collected using the Medical Research Council Scale for Muscle Strength data from 140 patients with a wider range of disorders, a small but significant improvement in overall strength was observed in the SCIg group (p < 0.0001). In addition, the results of two studies measuring health-related quality of life and patient satisfaction were pooled. Data from 49 patients suffering from MMN, CIDP, and a variety of different myopathies demonstrated a small but significant increase in the mean 36-Item Short Form Survey (SF-36) scores (p < 0.0001). A highly significant difference was revealed when comparing data from 119 patients' responses to the Life Quality Index questionnaire (LQI) assessing patient satisfaction (p < 0.0001). This is the first analysis showing that SCIg is more effective than IVIg in improving Patient Reported Outcomes in auto-immune neuromuscular disease. These results should permit a broad range of patients to self-administer immunoglobulin treatments at home, potentially improving patient acceptability while reducing hospital visits and healthcare costs for the treatment of chronic auto-immune neuropathies.
... 2,10 It is common for PIVC insertion to be a painful and invasive procedure, which therefore increases the anxiety and discomfort experienced by patients. [11][12][13][14] This affects their cognitive abilities and causes discomfort both mentally and physically. 15 To add to this, the anticipated pain prior to and upon cannulation significantly elevates a patient's level of anxiety. ...
Background:
Approximately 1.2 billion peripheral intravenous catheters are inserted across the world annually. It is known that intravenous cannulation may be a painful procedure, which affects cognitive abilities by increasing anxiety and discomfort.
Aim:
We hypothesized that inserting a smaller sized peripheral intravenous catheter has a lower level of pain sensation compared to a larger sized catheter.
Methods:
This observational, cross-sectional study was conducted between May and October 2016, in which surgical patients, aged 18 years or older, were eligible to participate. Experienced anesthesiologists and nurse anesthetists routinely obtained peripheral intravenous access according to the standards of care. The primary outcome was pain (verbal numeric rating scale, 0-10) upon intravenous cannulation.
Results:
A total of 1063 patients were included and they were divided into four groups: group 1, 22 gauge (N = 29); group 2, 20 gauge (N = 447); group 3, 18 gauge (N = 531); and group 4, sized over 18 gauge (N = 56). Inserting an 18-gauged peripheral intravenous catheter resulted in the lowest pain score (3.2 ± 2.0). As a result of the multivariate linear analysis, five factors were significantly associated with pain upon inserting a peripheral intravenous catheter (sex, American Society of Anesthesiology classification, a patients risk profile on the A-DIVA scale, site of cannulation on the extremity, and whether or not the attempt was successful); however, the size of the inserted peripheral intravenous catheter had no significant relation to the primary outcome.
Conclusion:
Inserting a smaller sized peripheral intravenous catheter did not result in a lower pain sensation. Moreover, to prevent pain upon inserting a peripheral intravenous catheter, an unsuccessful attempt must be avoided.
... Multiple puncture provokes delays in care, in obtaining diagnosis or in initiating treatment (2)(3)(4). Furthermore, it generates stress, heightens perceptions of pain and reduces satisfaction, both among patients and among the professionals performing the technique (4,5). ...
... It is acknowledged that two failed attempts constitutes a difficult PIVC insertion, and this, together with the limited availability of senior clinicians, means repeated failed attempts prior to more senior intervention is commonplace. [17][18][19][20] In emergency medicine literature, there has been recent recognition of the importance of PIVC placement, 21 the distress it can cause patients, 22 the associated costs 23 and potential complications, 24 leading to renewed enthusiasm and focus on improving performance. ...
Objective:
Failed attempts at peripheral i.v. cannula (PIVC) insertion in the ED are common. The psychological, physical and economic impact of these failures is significant. We sought to explore whether clinicians of differing experience levels can predict their own likelihood (clinician 'gestalt') of first-time cannula insertion success on any given patient.
Methods:
Data analyses from a prospective self-reported study assessing risk factors for first-time insertion success in a tertiary adult ED. We constructed and compared two simple theoretical clinical decision algorithms in an attempt to improve first-time PIVC insertion success rates.
Results:
This best algorithm identified a subgroup of 18% of the total PIVC population at higher risk of failure. This 18% comprised 57% of all PIVC failures, and implementation would result in a relative risk reduction of PIVC failure by 31%.
Conclusions:
When applied to our sample population, an algorithm relying on clinician gestalt to identify patients at high risk of PIVC failure had the greatest potential impact. These patients would be referred to expert PIVC inserters prior to, rather than after, failed attempts.
... When nurses are unable to obtain IV access in these patients, physicians are subsequently requested to attempt vascular access. As a result, these patients are often subjected to numerous IV placement attempts by multiple practitioners-which not only causes significant pain to the patient but also consumes considerable resources and time [10,11]. Ultimately, as a last resort, these patients often have to undergo central venous catheter (CVC) placement to obtain IV access. ...
... We ask the question: why does it matter that patients with poor IV access are more satisfied with nurses placing USGIVs compared to the traditional blind technique? The answer may be explained by current studies which show that patients experience varying degrees of stress, anxiety and pain during the placement of peripheral IVs [21][22][23]. A large study of 1.7 million satisfaction reports conducted by Wolosin showed that patients were dissatisfied with IV placement [24]. ...
Objective: Ultrasound (US) guidance for procedures is a well-established adjunct that improves the quality of patient care. Specifically, we assess the impact of nurse performed ultrasound-guided peripheral IV (USGPIV) placement on patient satisfaction with the procedure. Methods: We performed a randomized, prospective controlled study. 10 emergency department (ED) nurses were trained on USGPIVs which included a didactic and supervised placement of 10 US-guided IVs on live subjects. Another cohort of 10 ED nurses received a didactic on using traditional techniques to obtain IVs on difficult vascular access patients. Adult patients were enrolled based on strict inclusion criteria which identified them as having difficult vascular access. Once enrolled, the subjects were randomized into either the US-guided arm or the standard of care (SOC) arm, where the designated study trained nurses carried out peripheral IV placement. If the study nurse failed at IV placement, then a rescue IV was attempted by a non-study provider. The study was stopped once an IV was successfully placed. The patient was given a brief verbal survey to rate their experience from 1-10 (1 was poor and 10 was excellent) regarding the IV technique used by the study nurse. Results: 124 subjects were enrolled and randomized. 62 patients remained in the US-guided study arm and 53 patients in the SOC arm (2 were excluded due to lack of study nurse availability, and 7 patients were lost to followup). The median patient satisfaction in the US-guided group was 10 versus 8 for the SOC arm (p=0.04) Conclusion: Our study demonstrated that patient satisfaction is enhanced when nurses utilize the US-guided approach compared to the SOC palpation technique to establish an IV in difficult access patients. We recommend that nursing staff incorporate this method to IV access in difficult patients to enhance the quality of their patient care experience.
... One study identifies increases in patient pain when multiple insertions are compared to one insertion attempt. 30 Equally as important as procedural success is the prevention of post insertion PIVC failure. The dwell time of PIVCs inserted with a traditional approach in the ED is largely unknown. ...
Introduction Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency.
Methods and analysis We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule.
Ethics and dissemination The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used.
Trial registration number ACTRN12615000588594; Pre-results.
Background
Hypodermoclysis is a method of subcutaneous fluid administration. It has been used to treat palliative patients safely and effectively. However, the use of subcutaneous hydration is often overlooked.
Aim
This study aimed to compare the feasibility, pain experience and acceptability between subcutaneous and intravenous hydration in a hospital setting.
Methods
A prospective, randomised clinical trial was conducted. Patients requiring fluid administration were randomly allocated an intravenous or subcutaneous route. Patients’ pain score, satisfaction and acceptance levels were collected. The difficulty score of the needle insertion and acceptance scores from nurses were recorded.
Findings
A total of 26 patients were enrolled. The difficulty scores and patients’ pain scores were significantly lower in the subcutaneous group. The satisfaction and acceptance levels of the patients and nurses were similar in both groups. No systemic side-effects were found in either group.
Conclusion
Hypodermoclysis was acceptable and satisfying to patients and nurses. It was less painful than the intravenous route.
Objectives:
Peripheral intravenous (IV) access is a standard procedure in clinical settings. Nevertheless, previous studies have indicated that difficult peripheral IV access is prevalent in children. This study aimed to determine the prevalence and factors contributing to difficult peripheral IV cannulation in children admitted to a tertiary care hospital in Oman.
Methods:
This cross-sectional study was conducted from September to December 2015 at Sultan Qaboos University Hospital in Muscat, Oman. Nurses collected data concerning factors contributing to difficult IV access in children.
Results:
A total of 511 children undergoing cannulation during the study period were included in the analysis. Overall, 23.3% of the children experienced two or more cannulation attempts. The study identified three variables associated with successful cannulation in cases of difficult IV access. Visible veins were 2.72-times (95% CI: 1.58-4.68) more likely to be associated with success (p < 0.001), while palpable veins were 2.22-times (95% CI: 1.29-3.83) more likely to be associated with success (p = 0.004). However, scarring from previous IV access attempts was half (95% CI: 0.31-0.77) as likely to be associated with successful cannulation (p = 0.002).
Conclusions:
We identified statistically significant variables related to difficult IV cannulation in children, which we used to develop a prediction tool to assess the likelihood of difficult IV access in pediatric patients. Further research is necessary to validate the use of the difficult IV access prediction tool in this population.
Background
The term “difficult intravenous access” (DIVA) is commonly used but not clearly defined. Repeated attempts at peripheral intravenous catheter (PIVC) insertion can be a traumatic experience for patients, leading to sub-optimal clinical and economic outcomes. We conducted a systematic literature review (SLR) to collate literature definitions of DIVA, with the aim of arriving at an evidence-driven definition.
Methods
The SLR was designed to identify clinical, cost, and quality of life publications in patients requiring the insertion of a PIVC in any setting, including studies on US-guidance and/or guidewire, and studies with no specific intervention. The search was restricted to English language studies published between 1st January 2010 and 30th July 2020, and the Ovid platform was used to search several electronic databases, in addition to hand searching of clinical trial registries.
Results
About 121 studies were included in the SLR, of which 64 reported on the objectives relevant to this manuscript. Prevalence estimates varied widely from 6% to 87.7% across 19 publications, reflecting differences in definitions used. Of 43 publications which provided a definition of DIVA, six key themes emerged. Of these, themes 1–3 (failed attempts at PIV access using traditional technique; based on physical examination findings for example no visible or palpable veins; and personal history of DIVA) were covered by all but one publication. Following a failed insertion attempt, the most common number of subsequent attempts was 3, and it was frequently reported that a more experienced clinician would attempt to gain access after multiple failed attempts.
Conclusions
Considering the themes identified, an evidence-driven definition of DIVA is proposed: “when a clinician has two or more failed attempts at PIV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins) or the patient has a stated or documented history of DIVA.”
Study objective
Our objective was to develop a clinical scale (the VENSCORE) to predict pre-operative peripheral intravenous cannula (PIVC) insertion failure at the first attempt in adults.
Design
This was a prospective multicenter cohort study that included internal validation with bootstrapping.
Setting
The operating rooms of 14 hospitals in southern France from June 2016 to June 2018.
Patients
Consecutive adult patients aged 18 years or older were recruited upon arrival to the operating room, regardless of American Society of Anaesthesiology (ASA) physical status.
Interventions
PIVC insertion on arrival to the OR.
Measurements
PIVC insertion failure at the first attempt was the outcome of interest. Data collected included the number of PIVC insertion attempts and potential predictors of the risk of failure (including pre-operative patient characteristics and data relative to the procedure). Uni- and multivariable logistic analyses were performed. Based on these results, the VENSCORE scale was developed to predict the risk of failure of the first PIVC insertion.
Main results
In total, 3394 patients were included, and 27 were excluded because of protocol violations. The PIVC insertion failure rate at the first attempt was 20.3%. Based on multivariable analysis, a history of difficult PIVC insertions, high-risk surgery, poor vein visibility, and moderate to poor vein palpability were identified as risk factors for insertion failure at the first attempt. The area under the curve of the predictive model was 0.82 (95% confidence interval: 0.80–0.84). A VENSCORE value of 0 points was associated with a failure rate of 7%, versus 97% for a score of 6.
Conclusions
The four-item VENSCORE scale could be useful for prospectively identifying adults at risk of first PIVC insertion attempt failure.
Introduction:
Difficult intravenous (IV) access (DIVA) is frequently encountered in the hospital setting. Ultrasound-guided peripheral IV catheter (USGPIV) insertion has emerged as an effective procedure to establish access in patients with DIVA. Despite the increased use of USGPIV, little is known about the optimal training paradigms for bedside nurses. Therefore, we developed and evaluated a novel, sustainable, USGPIV simulation-based mastery learning (SBML) curriculum for nurses.
Methods:
This is a prospective cohort study of an USGPIV SBML training program for bedside nurses over a 12-month period. We evaluated skills and self-confidence before and after training and measured the proportion of the nurses achieving independent, proctor, and instructor status. Procedure logs and surveys were used to explore the nurse experience and utilization of USGPIV on real patients with DIVA 3 months after the intervention.
Results:
Two hundred thirty-eight nurses enrolled in the study. The USGPIV skill checklist scores increased from median of 6.0 [interquartile range = 4.0-9.0 (pretest) to 29.0, interquartile range = 28-30 (posttest), P < 0.001]. The USGPIV confidence improved from before (mean = 2.32, SD = 1.17) to after (mean = 3.85, SD = 0.73, P < 0.001) training (5-point Likert scale). Sixty-two percent of the nurses enrolled achieved independent status, 47.5% became proctors, and 11.3% course trainers. At 3-month posttraining, the nurses had attempted a mean of 35.6 USGPIV insertions with an 89.5% success rate.
Conclusions:
This novel USGPIV SBML curriculum improves nurses' insertion skills, self-confidence, and progresses patient care through USGPIV insertions on hospitalized patients with DIVA.
Highlights Stasis edema was the most common reason for difficult PIV access in the ICU. A robust US-guided PIV access technique training program was performed in our study. Trained nurses more successfully gained PIV access in patients with difficult access.
Purpose: The aim of this study was to compare nurse-performed ultrasound (US)-guided technique with standard of care (SOC) technique for difficult peripheral intravenous (PIV) access among patients admitted to the intensive care unit (ICU).
Materials and Methods: This was a randomized, prospective, open-label single-site study. ICU nurses completed a standardized training program for US-guided PIV access placement before patient enrollment. ICU patients with difficult PIV access were randomized to either nurse-performed US-guided technique or SOC technique. Primary outcome was success rate on the first attempt. Secondary outcomes were success rate after 2 attempts and frequency of complications after successful placement.
Results: A total of 60 patients were enrolled; 30 were randomized to receive US-guided technique, and 30 to SOC technique. Success rate on the first attempt was significantly higher with US-guided technique compared with SOC technique (70% vs 40%; P < 0.05). Success rates after 2 attempts were 73.3% for US-guided technique and 46.6% for SOC technique ( P = 0.065). Extravasation after successful placement occurred in 13.6% of patients with US-guided technique, and 28.6% of patients with SOC technique ( P = 0.394).
Conclusions: Among ICU patients with difficult PIV access, US-guided PIV access placement by nurses who underwent standardized training was more successful than placement with SOC technique.
Difficult peripheral venous access is commonplace in healthcare. It is disruptive to patient care, and failure to obtain venous access impedes delivery of care in a timely manner. Failure to obtain peripheral access may lead to central line placement and subsequent increased risk to the patient secondary to the many complications of central lines. Ultrasound-guided peripheral access allows clinicians to obtain peripheral access in situations where blind-, landmark-, or palpation-based techniques fail. The proper technique for ultrasound-guided peripheral venous access requires a different skill set than that of traditional intravenous catheter placement and is best performed in the long axis. It can be used to access the antecubital veins, the forearm veins, the saphenous vein or the deep veins of the upper extremity, the basilic vein, and the brachial veins. Utilizing ultrasound guidance for the placement of peripheral venous catheters leads to increased success, fewer needle sticks, fewer complications, and increased patient satisfaction compared to landmark- or palpation-based techniques in patients with difficult venous access.
Objectives:
Hand fractures and dislocations are common injuries in the pediatric population. This study aims to characterize the pediatric hand injuries that required closed reduction and identify those that required multiple reduction attempts.
Methods:
A retrospective cohort study was carried out in patients younger than 18 years of age with hand fractures or dislocations who underwent closed reduction in the emergency department (ED). Patients who ultimately required surgical reduction and fixation were not included.
Results:
Of the 310 hand injuries identified, 148 (114 fractures and 34 dislocations) underwent closed reduction in the ED; 7.4% of those required repeat reduction. Hand injuries that most often required repeat reduction included metacarpophalangeal joint dislocations (20.0%) and proximal phalanx neck (16.7%), metacarpal shaft (15.4%), metacarpal neck (6.2%), and proximal phalanx base (5.6%) fractures. No modifiable risk factors predicting the need for repeat reduction were identified.
Conclusions:
Some pediatric hand injuries are more likely to require repeat closed reduction by a hand surgeon. This retrospective study is the first step toward quality improvement as it provides opportunities for further research into the factors contributing to reductions that are unsuccessful at the first attempt. Identification of these factors and implementation of quality improvement measures are necessary to ensure the effective treatment of all pediatric hand injuries.
Background:
When intravenous access cannot be established using traditional methods of inspection/palpation, advanced methods are often required, leading to substantial delays in care. Knowing the likelihood of intravenous access failure can improve emergency department (ED) efficiency.
Objective:
Our aim was to validate prior need for an advanced technique to establish intravenous access as a predictor of failure to achieve access via traditional methods and to estimate the risk difference associated with this finding.
Methods:
We re-analyzed data collected for a clinical trial that randomized ED patients requiring intravenous access to one of two types of intravenous catheter; gauge size was selected by the inserter. The re-analysis pools data from both groups to examine predictors of failure to establish intravenous access by traditional methods, with failure defined as abandonment or use of an advanced technique (ultrasound guidance or external jugular vein catheterization). Confidence intervals for the difference between proportions were calculated using a normal binomial approximation.
Results:
We obtained data from 600 patients, with a median age of 52 years (interquartile range 36-63 years). We noted failure of traditional methods in 28 (4.7%) patients, including 17 of 109 (16%) with prior need for advanced techniques. The risk difference for prior need for advanced techniques versus no prior difficulty was 14% (95% confidence interval 7-22).
Conclusions:
Patients with a prior need for advanced techniques were 14% more likely to have failure of intravenous access by traditional methods than those without prior difficulty.
Background
It has previously been reported that venous cannulation‐induced pain (VCP) can be used to predict acute postoperative pain after laparoscopic cholecystectomy. Patients rating VCP ≥2.0 visual analogue scale (VAS) units had 3.4 times higher risk of moderate or severe pain. The purpose of this study was to evaluate if VCP ≥2.0 VAS units is associated with higher risk of acute postoperative pain after various common surgical procedures.
Methods
In a prospective clinical observational study, 600 male and female, 18‐80‐year‐old patients, scheduled for elective surgery, were included. The primary outcome measure was the difference in maximum postoperative pain intensity between low‐ (VCP <2.0) and high‐ (VCP ≥2.0) responders to VCP. Secondary outcome measures were the difference in proportion of patients with moderate or severe postoperative pain between low‐ and high responders, and potential influence of age, gender, and pre‐operative habitual pain.
Results
Patients scoring VCP ≥2.0 VAS units reported higher acute postoperative pain intensity levels than those scoring <2.0 (median 3.0 (IQR 0.0‐5.0) versus 0.2 (0.0‐4.0) VAS units, P=0.001), and also had 1.7 times higher risk of moderate or severe postoperative pain (P=0.005). Moderate or severe postoperative pain was reported by 38% of patients with VCP ≥2.0, and by 26% with VCP <2.0, VAS units (P=0.005).
Conclusion
Scoring of VCP intensity before surgery, requiring no specific equipment or training, is useful to predict individual risks of moderate or severe postoperative pain, regardless of patient age or gender, in a setting involving different kinds of surgery.
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Background:
When an intravenous (IV) catheter is needed and the common approach of inspection and palpation fails, an advanced access technique becomes necessary. Our objectives were to estimate pain scores, operator times, success rates, and complication rates when advanced techniques are used in a clinical setting.
Methods:
We enrolled patients who had a need for advanced IV access and were able to give informed consent to participate in our study. We collected data on operator type, technique, initial success, number of attempts, skin punctures, operator time, pain scores, and complications. We estimated confidence intervals for proportions using normal binomial approximation or exact calculation.
Results:
The registry documented 154 attempts in 116 patients. The median time from triage to establishment of an IV line was 203minutes; multiple advanced attempts were required in 24% of cases. Most attempts (95%) used either ultrasound-guided cannulation of a peripheral vein (PUG) (108) or cannulated the external jugular vein (EJ) (38). These 2 methods yielded similar pain scores (4.3-4.5), but PUG required more skin punctures (1.6 vs 1.2) and longer operator time (17.7 vs 11.9minutes). The only complication was IV line failure, occurring in 6% (95% confidence interval, 0%-18%) of EJ approaches and 27% (95% confidence interval, 18%-38%) of the PUG scenarios.
Conclusion:
Most attempts to establish IV access used PUG or the EJ. External jugular vein cannulation was achieved more quickly, with fewer skin punctures and a lower rate of postinsertion failure, than PUG.
Study objective:
This study compares first pass success rates and patient and physician satisfaction scores of using a guide wire-associated peripheral venous catheter (GAPIV) vs a traditional peripheral venous catheter in difficult to obtain venous access patients.
Methods:
A total of 200 patients were enrolled prospectively from a convenience sample in a large urban academic emergency department. Patients were included when they were deemed difficult access per study criteria. Patients were alternated to receiving either a traditional peripheral venous catheter or a GAPIV. The number of attempts, the number of catheters used, and patient and physician satisfaction scores were recorded.
Results:
A total of 100 patients were enrolled into each group. First attempt success was 85% with GAPIV vs 22% with the traditional peripheral venous catheter (P < .0001). Sixty-two percent of patients required a second stick with the conventional catheter compared to 15% with the GAPIV. The average number of attempts overall for the GAPIV product was 1.2 with an SD of 0.4 attempts vs 1.9 and an SD of 0.6 attempts with the traditional peripheral venous catheter; P < .0001. Using a 5-point Likert scale, the GAPIV had a median patient satisfaction score of 5 at insertion compared with the traditional peripheral venous catheter score of 2; P < .0001. Median physician satisfaction with the GAPIV study device was 5 at time of insertion, compared to 3 for the traditional peripheral venous catheter.
Conclusion:
The GAPIV product demonstrated significantly higher first attempt success and patient satisfaction compared to a traditional peripheral venous catheter in difficult to obtain venous access patients. Physician satisfaction was also favorable due to ease of access, time, and efficiencies gained.
Successful intravenous (IV) placement is important in the care of the acutely ill and injured pediatric patient. There are little data that exist regarding predicators of difficult IV access in pediatric Emergency Department (ED) patients who present to community EDs.
We retrospectively analyzed all pediatric charts for the calendar year 2012 from a single community teaching hospital. We identified all cases with patients less than 18 years of age in whom an IV or IV medications were ordered. We defined difficult IV access as those requiring more than one attempt, or those where the IV team was required to place the IV. We identified patient, provider, and procedural characteristics. Data were analyzed using descriptive statistics and univariate logistic regression to determine the odds ratio (OR) for predictors of difficult IV access.
We identified 652 patients, 607 (93%) without difficult access and 45 with difficult access. Increasing age [OR 0.94 (0.89-0.99) p = 0.017] was associated with decreased odds of difficult IV access. IVs attempted in the hand [OR 3.02 (1.06-8.58) p = 0.039] and lower extremity [OR 7.82 (2.27-26.91) p = 0.001)]) were associated with greater odds of difficult access than the antecubital fossa. Non-black/non-white race [2.37 (1.1-5.12) p = 0.028] was also associated with difficult IV access. Other factors (sex, IV catheter size, and so on) were not associated.
In this retrospective study of pediatric patients in a community ED, decreasing age, non-black/non-white race, and IV attempt location (hand and lower extremity vs. antecubital fossa) were associated with greater odds of difficult IV access.
The aim of the study was to determine some factors affecting pain during intravenous (i.v.) catheter placement in an emergency department (ED).
A cross-sectional, observational study was conducted at an academic ED. Nine hundred and twenty five adult patients who had a 20 gauge i.v. catheter placed were enrolled the study. Patients were excluded for the following conditions: more than one i.v. attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the i.v. site.
The magnitude of pain of i.v. catheter placement was not related to age, sex, experience of the individual placing the i.v. catheter, site of i.v. catheter insertion and use of analgesic or antidepressive drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressive patients (p = 0.001).
Depressive patients reported higher severity of pain during i.v. catheter placement than nondepressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.
Although frequently used and crucial in emergency care, peripheral intravenous access has been poorly documented. We examined whether criteria related to patient characteristics, underlying disease, devices, or environment were associated with difficult peripheral intravenous access.
Prehospital prospective observational study.
For each peripheral intravenous access attempt a questionnaire was filled in until final success or procedure abandonment. This questionnaire included data on the patient, operator, disease, degree of emergency, cannulation, nature of fluid infused and the use of gloves, environment, and particular medical observations such as recent peripheral intravenous access and chemotherapy. Criteria associated with peripheral intravenous access difficulty were identified comparing successful and unsuccessful attempts. A total of 671 attempts at peripheral intravenous access in 495 patients were studied.
The first attempt was successful in 368 cases (74%) and unsuccessful in 127 (26%). Final success was reported in all cases, including the use of central venous access in three cases. No abandonment was reported. Significantly correlated with a successful attempt were: the caliber of the catheter (OR 0.793), cannulation performed by a nurse specialized in emergency care (OR 3.959), lack of particular observations (OR 0.120), and a clean patient (OR 0.505).
Peripheral intravenous access was achieved in 99% of the patients in out-of-hospital settings. Improved success rate was reported when attempts were performed by a nurse specialized in emergency care using a 16- or 18-G catheter in clean patients without a particular medical history.
Background:
Peripheral venous (PV) cannulation, one of the most common technical procedures in Emergency Medicine, may prove challenging, even to experienced Emergency Department (ED) staff. Morbid obesity (body mass index [BMI] ≥ 40) has been reported as a risk factor for PV access failure in the operating room.
Objectives:
We investigated PV access difficulty in the ED, across BMI categories, focusing on patient-related predicting factors.
Methods:
Prospective, observational study including adult patients requiring PV lines. Operators were skilled nurses and physicians. PV accessibility was clinically evaluated before all cannulation attempts, using vein visibility and palpability. Patient and PV placement characteristics were recorded. Primary outcome was failure at first attempt. Outcome frequency and comparisons between groups were examined. Predictors of difficult cannulation were explored using logistic regression. A p-value <0.05 was considered significant.
Results:
PV lines were placed in 563 consecutive patients (53 ± 23 years, BMI: 26 ± 7 kg/m(2)), with a success rate of 98.6%, and a mean attempt of 1.3 ± 0.7 (range 1-7). Failure at the first attempt was recorded in 21% of patients (95% confidence interval [CI] 17.6-24.4). Independent risk factors were: a BMI ≥ 30 (odds ratio [OR] 1.98, 95% CI 1.09-3.60), a BMI < 18.5 (OR 2.24; 95% CI 1.07-4.66), an unfavorable (OR 1.66, 95% CI 1.02-2.69), and very unfavorable clinical assessment of PV accessibility (OR 2.38, 95% CI 1.15-4.93).
Conclusion:
Obesity, underweight, an unfavorable, and a very unfavorable clinical evaluation of PV accessibility are independent risk factors for difficult PV access. Early recognition of patients at risk could help in planning alternative approaches for achieving rapid PV access.
Study objectives:
Obtaining intravenous (IV) access in the emergency department (ED) can be especially challenging, and physicians often resort to placement of central venous catheters (CVCs). Use of ultrasound-guided peripheral IV catheters (USGPIVs) can prevent many "unnecessary" CVCs, but the true impact of USGPIVs has never been quantified. This study set out to determine the reduction in CVCs by USGPIV placement.
Methods:
This was a prospective, observational study conducted in 2 urban EDs. Patients who were to undergo placement of a CVC due to inability to establish IV access by other methods were enrolled. Ultrasound-trained physicians then attempted USGPIV placement. Patients were followed up for up to 7 days to assess for CVC placement and related complications.
Results:
One hundred patients were enrolled and underwent USGPIV placement. Ultrasound-guided peripheral IV catheters were initially successfully placed in all patients but failed in 12 patients (12.0%; 95 confidence interval [CI], 7.0%-19.8%) before ED disposition, resulting in 4 central lines, 7 repeated USGPIVs, and 1 patient requiring no further intervention. Through the inpatient follow-up period, another 11 patients underwent CVC placement, resulting in a total of 15 CVCs (15.0%; 95 CI, 9.3%-23.3%) placed. Of the 15 patients who did receive a CVC, 1 patient developed a catheter-related infection, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate.
Conclusion:
Ultrasound prevented the need for CVC placement in 85% of patients with difficult IV access. This suggests that USGPIVs have the potential to reduce morbidity in this patient population.
Objectives:
Emergency nurses (ENs) typically place peripheral intravenous (IV) lines, but if repeated attempts fail, emergency physicians have to obtain peripheral or central access. The authors describe the patient population for which ultrasound (US)-guided peripheral IVs are used and evaluate the success rates for such lines by ENs.
Methods:
This was a prospective observational study of ENs in a Level I trauma center with a census of 75,000, performing US-guided IV line placement on difficult-to-stick patients (repeated blind IV placement failure or established history). ENs were trained on an inanimate model after a 45-minute lecture. Surveys were filled out after each US-guided IV attempt on a patient. ENs could decline to fill out surveys, which recorded the reason for use of US, type of patient, and success. Successful cannulation was confirmed by drawing blood and flushing fluids. Descriptive statistics were used to evaluated data.
Results:
A total of 321 surveys were collected in a five-month period no ENs declined to participate. There were 280 (87%) successful attempts. Twelve (29%) of the 41 failure patients required central lines, 9 (22%) received external jugular IVs, and 20 (49%) had peripheral IV access placed under US guidance by another nurse or physician. Twenty-eight percent (90) of all patients were obese, 18% (57) had sickle cell anemia, 10% (31) were renal dialysis patients, 12% (40) were IV drug abusers, and 19% (61) had unspecified chronic illness. The remainder had no reason for difficult access given. There were four arterial punctures.
Conclusions:
ENs had a high success rate and few complications with use of US guidance for vascular access in a variety of difficult-access patients.
Pain is a common presenting complaint among emergency department (ED) patients. The verbal numeric pain scale is commonly used in the ED to assess self-reported pain. This study was undertaken to describe and compare pain scores in a variety of painful conditions and identify factors associated with self-reported pain scores.
The study was a prospective, observational, descriptive survey study conducted at an urban university hospital ED. Eligible participants included consenting adults 18 years and older, with an acute painful condition, who spoke English, and were not in severe distress. Through a structured interview, collected data included pain score; diagnosis; medical history; previous painful experiences; and demographic information including age, insurance status, and highest level of education completed.
Among 268 eligible participants, 263 (98%) consented and completed the study protocol. Seventy-one percent of participants were 50 years old or younger; 55%, women; and 68%, white. Fifty-four percent had private insurance, and 81%, high school education or higher. The most common chief complaints were soft tissue injury (33%), abdominal pain (18%), and chest pain (13%). The median self-reported pain score was 7/10 (mean, 6.7; interquartile range, 6-9; range, 0-10). The most common previous painful experiences were childbirth (21%), major trauma (18%), and surgery (14%). Participants cited reasons for self-reported pain scores, including current feeling of pain (62%), comparison to previous pain (31%), and comparison to hypothetical pain (12%). The number of previous ED visits was positively correlated with current pain score (Spearman correlation R = 0.28; P < .001). The chief complaints associated with the highest pain scores included dental pain (mean pain score, 8.5) and back pain (mean pain score, 7.6). Chief complaints associated with the lowest pain scores included chest pain (mean pain score, 5.2) and other medical conditions (mean pain score, 5.3). Factors associated with higher pain scores included younger age (P < .001, Kruskal-Wallis), Medicaid insurance (P = .02), and lower educational status (P = .01). There was not a statistically significant association between current pain score and sex, race, previous painful experiences, or number of hospital admissions.
Emergency department patients with acute painful conditions report a wide range of self-reported pain scores. Participants rated pain based on current feeling of pain or comparison to previous or hypothetical pain. Chief complaints with highest pain scores included dental pain and back pain. Factors associated with higher pain scores included younger age, Medicaid insurance, lower educational status, and higher number of previous ED visits.
To determine whether the use of a near-infrared light venipuncture aid (VeinViewer; Luminetx Corporation, Memphis, Tenn) would improve the rate of successful first-attempt placement of intravenous (IV) catheters in a high-volume pediatric emergency department (ED).
Patients younger than 20 years with standard clinical indications for IV access were randomized to have IV placement by ED nurses (in 3 groups stratified by 5-year blocks of nursing experience) using traditional methods (standard group) or with the aid of the near-infrared light source (device group). If a vein could not be cannulated after 3 attempts, patients crossed over from one study arm to the other, and study nurses attempted placement with the alternative technique. The primary end point was first-attempt success rate for IV catheter placement. After completion of patient enrollment, a questionnaire was completed by study nurses as a qualitative assessment of the device.
A total of 123 patients (median age, 3 years) were included in the study: 62 in the standard group and 61 in the device group. There was no significant difference in first-attempt success rate between the standard (79.0%, 95% confidence interval [CI], 66.8%-88.3%) and device (72.1%, 95% CI, 59.2%-82.9%) groups. Of the 19 study nurses, 14 completed the questionnaire of whom 70% expressed neutral or unfavorable assessments of the device in nondehydrated patients without chronic underlying medical conditions and 90% found the device a helpful tool for patients in whom IV access was difficult.
First-attempt success rate for IV placement was nonsignificantly higher without than with the assistance of a near-infrared light device in a high-volume pediatric ED. Nurses placing IVs did report several benefits to use of the device with specific patient groups, and future research should be conducted to demonstrate the role of the device in these patients.
We compared the efficacy, acceptability, and safety of a topical vapocoolant alkane spray and 1% plain s.c. lidocaine in reducing pain from i.v. cannulation.
This was a non-blinded, randomized, controlled trial, in a large emergency department. Adult patients requiring i.v. cannulation were enrolled. The vapocoolant was administered from a pressure pack, at a distance of 12 cm for 2 s, and cannulation was undertaken within 15 s. Alternatively, 1% plain lidocaine 0.2 ml was administered s.c. using a 27 G needle, and cannulation was undertaken after a minimum of 30 s. The primary outcomes were anaesthetic administration and cannulation pain (0-100 mm visual analogue scale). Convenience of anaesthetic use and patient satisfaction were measured using a five-point Likert scale.
One hundred and ten patients were enrolled in each group. The groups did not differ in age, gender, cannulation anxiety, cannulator experience, cannulation indication or site, or cannula size. Median anaesthetic administration pain scores were 0 and 11 mm in the vapocoolant and lidocaine groups, respectively (P<0.001). Median cannulation pain scores were 9 and 0 mm, respectively (P<0.001). Vapocoolant was associated with greater cannulation success (83.6% vs 67.3%, P=0.005), less time to administer (median 9.0 vs 84.5 s, P<0.001), and more staff convenience (median 5 vs 4, P<0.001). Median patient satisfaction was 4 in both groups. Unexpected events were rare and minor.
Although vapocoolant reduces cannulation pain less than lidocaine, it has a number of important advantages. Vapocoolant offers a useful alternative in the emergency department setting.
We evaluated the efficacy and safety of emergency department technicians' (EDT) use of ultrasound (US) guided peripheral intravenous (PIV) access compared to the traditional approach on a subset of patients with difficult IV access.
We enrolled a convenience sample of 75 ED patients with difficult IV access (at least 2 failed PIV attempts). During phase I, EDTs used the standard technique. EDTs then attended a didactic session on ultrasound guided PIV access of the upper extremity. In phase II, the EDTs used US guidance for PIV access. Outcome measures were successful PIV cannulation by an EDT, time to cannulation, medical doctor (MD) or registered nurseRN intervention, complications, patient satisfaction, and number of skin punctures.
Successful cannulation rates were similar (US: 33/41, 80.5%; traditional technique: 24/34, 70.6%) (difference: 9.9%; 95% confidence interval (CI): -9.3%, 29.1%). US was 2.0 times faster (CI 1.3, 3.1), required less MD/RN intervention (7.3% vs. 20.6%) (difference: 13.3%; CI: -2.5, 30.2%), had fewer complications (41.5% vs. 64.7%, difference: 23.3%; CI 0.6%, 42.7%) and skin punctures (1.6 vs. 3.6; difference: 2.0; CI: 1.6, 2.7), and improved patient satisfaction from 4.4 to 7.7 cm (P-value = .0001).
Following a brief US training for PIV access, EDTs showed similar success rates but US had significantly improved speed and patient satisfaction with fewer skin punctures and complications.
To determine the rate of unnecessary intravenous (IV) access in the emergency setting.
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.
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).
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.
To compare patient and practitioner assessments of pain associated with commonly performed emergency department procedures and use of anesthetics before these procedures.
This was a prospective, observational, cross-sectional study conducted at a university-based ED with a convenience sample of ED patients. Research assistants recorded the procedure performed and historical and demographic information on standardized data collection instruments. After each procedure, both the patient and practitioner independently recorded assessments of patient pain on a 100-mm visual analog scale (VAS). Use of preprocedure anesthetics and patient preferences regarding their use were also identified. Categorical variables were analyzed by chi(2) tests. Patient and practitioner VAS scores were compared using a paired t test; alpha was preset at .05. Correlation coefficients were calculated to assess correlation between patient and practitioner pain scores.
A total of 1,171 procedures were evaluated for the 15 most common procedures performed. The mean patient age was 42.8+/-18.7 years and 46.1% were male. Overall, the mean patient VAS was 20.8 mm+/-25.1 mm; the mean practitioner VAS was 23.5 mm+/-20.3 mm. The mean difference between groups was 3.0 mm (95% confidence interval [CI], 1.3 to 4.1). Correlation between patient and practitioner pain scores for individual procedures was poor to fair (r=.26 to.68). The most painful procedures according to patients in descending order were nasogastric intubation, abscess drainage, fracture reduction, and urethral catheterization. Local anesthetics were administered in 12.8% of procedures yet would be requested before similar future procedures by 17.1% of patients. Patients who would choose local anesthetics in the future gave higher pain scores than those who would not (43.3 mm versus 16.3 mm; mean difference=27.0 mm, 95% CI, 22.2 to 31.8 mm).
The most painful procedures for ED patients were nasogastric intubation, incision and drainage of abscesses, fracture reduction, and urethral catheterization. Although practitioners also identified these procedures as most painful, the correlation between patient and practitioner pain assessments in individual patients was highly variable. Overall use of anesthetics before these procedures was low. Practitioners should be attentive to their patients' individual anesthetic needs before performing painful procedures.
The study was undertaken to determine whether pain perception is different in elderly patients than in younger patients.
A cross-sectional, observational study was conducted at 2 urban academic emergency departments. Adult patients (> or =18 years of age) who required an 18-gauge intravenous catheter as part of their ED care were eligible. Patients were excluded for the following conditions: more than one attempt at intravenous catheter placement, altered mental status, visual impairment, intoxication, distracting pain, or abnormal upper extremities. Patients were asked to indicate on a 10-cm visual analog scale (VAS) the amount of pain they had at baseline immediately before intravenous catheter placement. They were then asked to indicate on a separate VAS the amount of pain caused by intravenous catheter placement. Patients aged 65 years and older were defined a priori as elderly.
Of 100 patients enrolled in the study, 32 (32%) were elderly. Elderly patients reported significantly less pain than nonelderly patients (Delta = -15 mm, 95% confidence interval -26 to -4 mm). Pain of intravenous catheter placement was not associated with sex, baseline pain, site of intravenous catheter insertion, or level of training of the individual placing the intravenous catheter.
Elderly patients experienced less acute pain than their younger counterparts in response to a standardized stimulus in a clinical setting. This difference is both statistically and clinically significant. This may have clinical implications for the assessment and treatment of acute pain in the elderly.
In a landmark hypothesis-generating study, Todd et al found that a difference of approximately 13 mm (95% confidence interval [CI] 10 to 17 mm) on a visual analog scale (VAS) represented the minimum change in acute pain that was clinically significant in a cohort of trauma patients.
We test the hypothesis that the minimum clinically significant change in pain as measured by the VAS in an independent, more heterogeneous validation cohort is approximately 13 mm.
This was a prospective, observational cohort study of adults presenting to 2 urban emergency departments with pain. At 30-minute intervals during a 2-hour period, patients marked a VAS and were asked if their pain was "much less," "a little less," "about the same," "a little more," or "much more." All data were obtained without reference to prior VAS scores. The minimum clinically significant change in pain was defined a priori as the difference in millimeters between the current and immediately preceding VAS scores when "a little more" or "a little less pain" was reported.
Ninety-six patients enrolled in the study, providing 332 paired pain measurements. There were 141 paired measurements designated by patients as "a little less" or "a little more" pain. The mean clinically significant difference between consecutive ratings of pain in the combined "little less" or "little more" groups was 13 mm (95% CI 10 to 16 mm). The difference between this finding and that of Todd et al was 0 mm (95% CI -4 to 4 mm).
These data are virtually identical to previous findings indicating that a difference of 13 mm on a VAS represents, on average, the minimum change in acute pain that is clinically significant.
The study was to determine the effect of preexisting pain on the perception of a painful stimulus. We conducted a cross-section study at an urban ED using convenience sampling. Adult patients who had a 20-g IV catheter placed as part of their ED care were eligible for the study. Patients were excluded for the following reasons: more than one IV attempt, altered mental status, visual impairment, intoxication, or a physical abnormality at the IV site. Patients were asked to indicate on a 10-cm visual analog scale (VAS) the amount of pain they had at baseline immediately before IV placement. They were then asked to indicate on a separate VAS the amount of pain caused by the IV placement. Correlation between baseline pain and pain of the IV was assessed using Pearson's rho. One hundred patients were enrolled in the study. The pain of IV placement did not differ significantly by gender, race, who placed the IV, or the location of the IV. The correlation between baseline pain and pain of the IV placement was poor (rho =.14, confidence interval:-.06-.33). The response to a standardized painful stimulus among ED patients does not correlate highly with the severity of preexisting pain.
We compare the analgesic efficacy of topical anesthetics for dermal instrumentation with conventional infiltrated local anesthesia and also compare topically available amide and ester agents with a eutectic mixture of local anesthetics (EMLA).
We conducted a systematic review of randomized, controlled trials. Relevant literature was identified through searches of MEDLINE, Cochrane Central Register of Controlled Trials, and the Excerpta Medica Database Drugs and Pharmacology. We limited the type of procedures to puncture of intact skin with a needle. The primary outcome was analgesic efficacy, reflected in the patient's self-report of pain intensity during dermal instrumentation. Where possible, quantitative methods were used to summarize the results.
We identified 25 randomized controlled trials including 2,096 subjects. The results of the trials comparing the efficacy of EMLA with infiltrated local anesthetic were inconsistent. Qualitative analysis demonstrated comparable analgesic efficacy between liposome-encapsulated lidocaine and EMLA. The weighted mean difference in 100-mm visual analogue scale pain scores favored topical tetracaine over EMLA (-8.1 mm; 95% confidence interval -15.6 mm to -0.6 mm). Liposome-encapsulated tetracaine provided greater analgesia than EMLA according to the weighted mean difference in 100-mm visual analogue scale scores (-10.9 mm; 95% confidence interval -15.9 mm to -5.9 mm).
EMLA may be an effective, noninvasive means of analgesia before dermal procedures. However, we identified 3 topical anesthetics that are at least as efficacious as EMLA: tetracaine, liposome-encapsulated tetracaine, and liposome-encapsulated lidocaine. Liposomal lidocaine is commercially available in the United States and offers a more rapid onset and less expensive alternative to EMLA.
Emergency nurses (ENs) typically place peripheral intravenous (IV) lines, but if repeated attempts fail, patients usually receive central line access. To measure the effect of ultrasound (US) guidance on the perceived difficulty of EN peripheral IV access in Emergency Department patients, a prospective observational study was conducted of ENs in a level I trauma center with a census of 75,000, performing US-guided IV line placement in difficult stick patients (difficult or hard stick patients defined as repeated blind IV placement failure or established history of blind IV placement failure). ENs trained on an inanimate model after a 45-min lecture. Surveys were filled out after each US-guided IV attempt on a patient. ENs could decline to fill out surveys, which recorded reason for US use, type of patient, success, technique used, and difficulty. Successful cannulation was confirmed by drawing blood and infusion of 100 mL of IV fluids. Student's t-test was used to compare data. A total of 321 surveys were collected in a 5-month period; no ENs declined to participate. There were 258 (80%) of the patients rated as very hard sticks before US, 59 as hard, 3 as easy, and none as very easy. Of the 258 very hard sticks without US, 29 were still rated as very hard even with US use; 43 changed to hard, 112 changed to easy and 137 to very easy. After a brief tutorial, ultrasound guidance for IV access in emergency patients significantly decreased the perceived difficulty in difficult access patients.
Although intravenous (i.v.) line placement is a common procedure in the emergency department (ED), it is an uncomfortable experience for many patients. Topical analgesic agents are rarely used because they have long onsets of action and thereby cause unacceptable treatment delays. Cryoanaesthesia, the use of cooling agents to reduce pain, has been recognised for many years as a potential pain management strategy. The purpose of this study was to determine whether an instantaneous topical skin coolant spray reduces patient's pain during i.v. cannulation and represents a feasible alternative for cutaneous analgesia in the ED setting.
We conducted an unblinded, randomised, controlled study, in a convenience sample of ED patients. Utilising a random number generator to assign patients to the control or study group, patients over the age of 18 years who required i.v. cannulation as part of their evaluation were enrolled at two tertiary care hospitals. In both groups, i.v. lines were placed in accordance with accepted clinical standards of practice, with the single addition of the coolant spray delivered to the i.v. site before needle insertion in the study group. All study participants answered questionnaires before and after i.v. placement and rated pain during procedure on a 100 mm visual analogue scale.
Of the 92 patients enrolled in the study, 47 (51.1%) were randomised to the study group and received the anaesthetic spray, and 45 (48.9%) were randomised to the control group and had their i.v. placed in a standard method. 66 patients were female (71.8%) and 26 (28.2%) were males. The mean pain score in the study group was 27 mm (95% confidence interval (CI) 19.9 to 34.1 mm) and 28 mm (95% CI 20.4 to 35.6 m) in the control group (p = 0.934). Subgroup analysis of female and male patients did not show significance.
Our study failed to detect a difference in pain perception resulting from the pre-procedural application of a skin coolant associated with i.v. placement in the ED setting.