Ultrasound Guided Peripheral Intravenous Access Correlation with Emergency Department Holds
EMERGENCY ULTRASOUND SECTION
Morgan Ritz, MD
A
bstract
Establishing peripheral intravenous (PIV) access is an essential and rate limiting step in providing patient care in at least one-fourth of Emergency Department (ED) patients and almost all admitted patients.1 Placing a PIV can be particularly challenging in the ED where patients frequently present with hypovolemia, sepsis, combativeness, scarred limbs, or other limiting conditions.3 As patient numbers increase intrahospital, ED patient holds increase as well.4,5 In addition, emergency physicians at sites without a PIV team perceive that they get requests to place more ultrasound guided peripheral intravenous catheters (USGPIVs) when there are more ED holds. Data was collected at our main teaching hospital, Crozer Chester Medical Center, over a three month period between total number of ED patients, total number of ED patient holds, and total USGPIVs placed. A positive correlation was found to show that as ED patient holds increase, USGPIVs also increase. Further data would need to be gathered to determine if specially designated PIV teams, nurses, or techs completing this task leads to more physician time being spent managing other aspects of patient care.
Introduction Establishing peripheral intravenous (PIV) access is an essential and rate limiting step in providing patient care in at least one-fourth of Emergency Department (ED) patients and almost all admitted patients.1 PIV access is essential not only for critical patient medication administration but also in non-critical patients for laboratory testing and med administration. Placing a PIV can be particularly challenging in the ED where patients frequently present with hypovolemia, sepsis, combativeness, scarred limbs or other limiting conditions.3 Patients with difficult IV access can be subjected to painful and repeated access attempts, delays in care, and increased risk of complications such hematomas, bleeding, infection, and thrombosis.2 If peripheral access is especially difficult or cannot be obtained, a patient may receive a central venous catheter or midline catheter. A midline catheter for access is becoming more popular in admitted patients with difficult IV access, however this line may be placed by nonemergency medicine clinicians, such as Interventional Radiology (IR), during day time hours depending on hospital specific protocols. This may not always be helpful for the ED care teams which run with a constant influx and efflux of patients with frequent care needs. As patient numbers increase intrahospital, ED patient holds increase as well.4,5 ED patient holds are patients who are placed in the hospital under observation or admission status but are waiting in the ER until an inpatient bed is available. Holding a patient in the ED consumes provider and nursing time and efforts. Holds can lead to decreased time to pain management, increased adverse outcomes, increased wait times as well
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as patients who leave without full evaluation.6 In addition, emergency physicians at sites without a PIV team have the impression that they get requests to place more USGPIVs when there are more ED holds. The procedure may take only 10-15 minutes in set up, material gathering, and procedure completion, however this time builds up a burden on ER physicians who are trying to see new patients, admit or discharge current ones, and even triaging or screening the waiting room as patients waiting to be seen increase as the ED patient hold number increases.9
Methods The primary objective of this study was to determine the number of USGPIV performed compared with the number of ED holds in discreet 24-hour periods. This study did not have a control or comparison group. The secondary objectives were to determine the number of patients requiring central venous access or midline after USGPIV placement by the ED and the maximum number of USGPIVs placed in the same patient. The study is a prospective chart review comparing the number of USGPIV placed by physicians and the number of ED patient holds. Data was obtained from patient charts from August 2021 to October 2021 at Crozer Chester Medical Center Emergency Department (ED). An ED “hold” was defined as a patient who is placed in observation or admitted to the hospital for over four hours, a crisis patient being held in the ER over four hours, or a transfer patient who is being held in the ER for over four hours. Inclusion criteria included any patient seen in the ED. Exclusion criteria included patients in the waiting room or ED patients that have been discharged. In a 24-hour period the number of total ER patients (excluding waiting room patients), number of ER hold patients, and USGPIVs was collected twice, about twelve hours apart. The numbers were averaged for each 24-hour period and plotted on a scatter plot with the X-axis representing the number of holds in the department and the Y-axis representing the number of USGPIVs recorded.
Results Data was collected over a three month period at our main hospital location of Crozer Chester Medical Center as this is our largest teaching hospital with 24-hour resident ED coverage. However, certain days were excluded during data collection, including resident physician conference days and journal club days, when the residents are not in the department. These USGPIVs needed to be logged in the chart to be considered part of the data set. Data was concluded over three months with a total of 66 days of data at the end of the collection. Figure 1 illustrates the general trend showing USGPIVs compared to total ED patients and ED patient holds over the three months. The correlation coefficient was
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