Improving Adherence to Best Practices and Clinical Outcomes in Difficult Intravenous Access Patients
Annals of Emergency Medicine
Objectives: Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. Many DIVA patients are poor candidates for standard techniques and require ultrasound-guided IV (USIV) placement. This procedure has become more common, yet training is often minimal, not standardized, and without clear endpoints for competency. Following established best practices for USIV placement has been shown to improve clinical outcomes. Literature suggests most clinicians do not adhere to these guidelines and may even be unaware of them. The impact of education and training of emergency department (ED) staff on vascular access in this vulnerable population remains unclear. We aim to demonstrate the success of a teaching program (Operation STICK) on improving adherence to vascular access best practices in the ED and improved vascular access outcomes in DIVA patients. Methods: This was an observational cohort analysis conducted at a tertiary care ED with 120,000 annual visits and 1,100 hospital beds. Adult patients requiring USIV insertion in the ED between April 1st, 2022, and March 30th, 2023, were eligible participants. ED clinicians of all levels were voluntarily trained in IV access by a teaching program, Operation STICK (OSTICK), during this time. Descriptive statistics of the study demographics, hospital course, USIV characteristics, and outcomes were performed. The primary outcome was the proportion of catheter dwell time to the hospitalization length of stay. Secondary outcomes included: time to USIV placement, site selection, PIVC failure, complications, and hospital length of stay. Results: 3,867 USIVs placed in the ED were included in this study. 2,282 (59.0%) were placed by OSTICK-trained staff and 1,585 (41.0%) by non-OSTICK-trained staff. The average age was 59.49 years and 67.4% was female. The time from ED arrival to USIV insertion was significantly faster among OSTICK-trained staff (mean ¼ 3.52 hours vs 6.97 hours; p<0.001). Further, AC fossa placement was 13.8% lower in OSTICK trained staff (p<0.001). Among admitted patients, the median proportion of USIV dwell time to the entire hospital length of stay was 89.0% among OSTICK USIVs, compared to 70.0% among non-OSTICK USIVs (p¼0.006). Hospital length of stay reduced from 184.37 hours to 178.11 hours with OSTICK-trained USIV placement (p¼0.466). The complication rate was in 37.3% of OSTICK USIVs compared to 41.1% of non-OSTICK USIVs (p¼0.232). Conclusions: In conclusion, the results of this study demonstrate that instituting a comprehensive vascular access program can successfully improve adherence to best practices and clinical outcomes for patients requiring USIV placement in the ED. The training program resulted in faster USIV insertion times, improved insertion practices, and a higher proportion of catheter dwell time to hospital length of stay.
Zimmerman T, Mielke N, Bahl A. Improving adherence to best practices and clinical outcomes in difficult intravenous access patients. Ann Emerg Med. 2023 Oct;82(4 Suppl.):S15. doi:10.1016/j.annemergmed.2023.08.054