Paramedic decisions with placement of out-of-hospital intravenous lines

Paramedic Decisions With Placement of Out-of-Hospital Intravenous Lines STEVEN A. PACE, MD,* FREDERICK P. FULLER, NREMT-P,1TIMOTHY J. DAHLGREN, MD::I: To determine the incidence of unused out-of-hospital intravenous line (IV) placements, we prospectively studied IV placement in emergency medical services (EMS) patients. Unused IV placement was defined as any patient having an EMS initiated IV that was not used for fluid bolus or medication administration in the field or in the emergency department (ED). Data were analyzed on placement and use of IV lines in the field and in the ED, transport time, years of paramedic practice, and paramedic student presence. Of 290 patients, 155 had an IV initiated (147) or attempted (18). Twenty-nine percent (84 of 290) of the patients received an unused EMS IV. One hundred twenty-five patients had no IV initiated by EMS. Seven subsequently had an IV started and used in the ED, for an undertreatment rate of 2.4% (7 of 290). The presence of a paramedic student increased the odds of an unused IV 1.4 (95% CI, 1.1 to 2.0). IVs are frequently started and not used. (Am J Emerg Med 1999;17:544-547. Copyright © 1999 by W.B. Saunders Company) Some emergency medical services (EMS) systems allow paramedics operating under standing orders to initiate intravenous (IV) line placement for out-of-hospital patients. Often this is accomplished based on the paramedic's clinical judgment without on-line physician contact. Numerous factors may enter into this decision-making process, including perceived severity of illness or injury, distance to the receiving center, provider experience level, and the presence of paramedic students. There has been much debate in the emergency medicine literature questioning the value of out-of-hospital interventions. 1-5 This is especially true for EMS-initiated IV. 6-1° To date, only 2 abstracts have reported on the use of EMS IV line placement, a common paramedic task. Gausche et al 6 found a 56% overtreatment rate amongst 452 patients transported by paramedics in their system. Allen et al7 found a 22% rate of nonutilization amongst 802 total patients transported. Previous work on emergency medical services (EMS)initiated IV lines has primarily focused on 3 areas: success

From the *Madigan Army Medical Center, Department of Emergency Medicine, Ft Lewis, WA; l-American Medical Response, Tacoma, WA; and :~Good Samaritan Hospital, Department of Emergency Medicine, Puyallup, WA. Manuscript received February 18, 1998, returned April 1, 1998; revision received June 2, 1998, accepted September 15, 1998. Presented at the 1997 American College of Emergency Physicians Research Forum, San Francisco, CA, October 1997. The opinions expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government. Address reprint requests to Dr Pace, 40 Bonney St, Steilacoom, WA 98388. Key Words: Paramedic, intravenous line, emergency medical services. Copyright © 1999 by W.B. Saunders Company 0735-6757/99/1706-0010510.00/(3 544

rates, infection, and on-scene times. Numerous papers have shown that paramedics have high success rates 11-13 ( > 9 0 % ) for initiating IVs, even while in a moving ambulance. 14 Early reports suggested an increased incidence of infection among EMS-initiated IVs 15 (34%), whereas a subsequent, larger study dispelled this idea (0.12%). 16 Others have shown a prolonged on-scene time for the establishment of IVs, which is especially concerning in the trauma patient. 4,9J° Whether the IV was necessary or beneficial is a question for investigation. The purpose of this study was to determine the appropriateness and utilization of out-ofhospital-initiated intravenous lines.

METHODS We evaluated the hypothesis that the incidence of unused IV line placements was greater than 10%, and that more unused placements occurred when transport times exceeded 10 minutes, when the paramedic had less than 2 years' experience, and when a paramedic student was present. We conducted a prospective observational study on a consecutive cohort of out-of-hospital patients. These pediatric and adult patients were transported by a private paramedic service to 2 local, suburban emergency departments that also served as base stations. Emergency medical services were provided by American Medical Response, a private advanced life support ambulance service functioning as part of the county system and operating approximately 20 ambulances, over a variety of shifts, staffed with 1 paramedic and 1 emergency medical technician (EMT). Paramedics respond to primary 911 calls, private calls, and requests for interfacility transports. The service area contains urban, suburban, and rural parts of Pierce County, Washington (population approximately 600,000). These areas are served by a variety of EMS configurations including all-volunteer first responders, to areas with full-time, paid paramedics from both public and private sources. Paramedics function under standing orders for IV placement at their discretion, depending on their patient assessment. Although the ambulance service bills separately for IV initiation, the field paramedic is unencumbered by this action, and decision making is not influenced by any potential financial incentive. Patients were identified by means of a daily review of all patients transported by this service. EMS run reports and Emergency Department (ED) records were reviewed using a standardized data collection tool. All patients transported to the 2 participating EDs were included for analysis. Patients were excluded if they were being transported between medical facilities, if an IV line was already in place, or if they were not admitted to the ED. Patients were followed to determine whether an IV line was initiated or attempted out-of-hospital or in the ED. Data were collected regarding use of the IV for fluid bolus or medication administration out-of-hospital or within 1 hour of ED arrival. If the IV was not used during this timeframe, we defined it as an unused. Other data obtained included age and gender of the patient, transport times, paramedic experience level in years (from human resource records

PACE ET AL • PARAMEDIC DECISIONS AND IV LINES

so as to preserve paramedic blinding), the presence of a paramedic student, and the paramedic clinical impression. Paramedics and ED staff were unaware (blinded) that a study was being conducted, and there had been no recent focus on IV therapy that would heighten awareness. Patients were placed into 1 of 4 groups based on the outcome of the paramedic's decision to initiate or not initiate an EMS IV. The first group was the unused IV placement (overtreatment) and was defined as any patient having an EMS-initiated (or attempted) IV that was not used for either fluid bolus (greater than 200 mL) or medication administration, in the field or within the first 60 minutes of the ED stay. The next group, undertreatment, was defined as any patient without an EMS-initiated IV (or attempt) who subsequently required an ED-initiated IV and either fluid bolus or medication administration, within the first 60 minutes of the ED stay. Finally, the 2 appropriate groups consisted of those patients whose EMS IV was used for either fluid bolus (greater than 200 mL) or medication administration, in the field or within the first 60 minutes of the ED stay, and those patients who did not receive an EMS IV and did not require one in the first 60 minutes of the ED stay. Considering the primary hypothesis, an a priori power analysis (with an m-level of 0.05 and a [3-level of 0.20) determined we would need to enroll 144 patients with an IV placement or attempt to show that a greater than 10% unused IV placement rate (overtreatment) was present. We chose this percentage based on preliminary study data. Local Institutional Review Board approval was obtained. Proportions are expressed as percentages with 95% confidence intervals. Odds ratios with 95% confidence intervals were calculated for the following variables: transport times greater than 10 minutes, less than 2 years of paramedic experience, and presence of a paramedic student. Categorical data were analyzed using chisquare analysis.

RESULTS Three hundred patients were transported during the 34day study period. Two hundred ninety patients met the inclusion criteria. Ten were excluded because of a preexisting IV line or direct admission to the hospital bypassing the ED. One hundred sixty-five (57 _+ 6%) of the patients transported received an IV out-of-hospital. The patient distribution is shown in the Figure. The unused IV placement rate (overtreatment) was 29% (_+5%). One hundred twenty-five patients did not receive an EMS IV line. Seven patients received an IV in the ED (6 medication, 1 fluid bolus), for an undertreatment rate of 2.4% ( + 1.8%). All IVs were started at the discretion of the paramedic. There were no cases of intraosseus needles being attempted. The addi-

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TABLE 1. Overtreatment Odds Ratios

Parameters

Odds Ratio

95% Confidence Intervar

Transport time >10 minutes Paramedic experience <2 years Paramedic student present

1.13 1.02 1.44

0.84, 1.54 0.65, 1.61 1.07, 1.95

tional hypothesized differences are shown in Table 1. Only the presence of a paramedic student reached statistical significance and slightly increased the patient's odds (1.44) of having an unused IV line initiated. The overall successful EMS IV placement was 89% (147 of 165). Of the 18 unsuccessful IV attempts, 12 patients were in the overtreatment group, and 6 were in the appropriate group. The characteristics of the patient population are shown in Table 2. Major trauma includes any patient meeting the Washington State Prehospital Trauma Triage tool, which is modeled after the American College of Surgeons. Minor trauma includes all other injuries. Medical includes all other patients that were neither traumatic conditions nor in the pediatric age-group. Patients with chest pain that was possibly related to coronary artery disease were subclassified in the medical category.

DISCUSSION IV placement is a common out-of-hospital occurrence in an Advanced Life Support (ALS) system. In our study, 57% of the 290 consecutive patients transported had an IV placed. In their study of 452 patients transported by an urban paramedic system, Gnasche et al 6 found that 84% had an IV initiated. Allen et al 7 described an IV placement rate of 50% (398 of 802) in EMS patients. Such a common occurrence deserves investigation regarding use and benefit. Guasche et al 6 determined that 56% of EMS patients (253 of 452) were overtreated with IV lines placed inappropriately and 7% (33/452) were considered undertreated, with needed IV lines not placed. Their determination of appropriate treatment was based on predetermined criteria, which were not discussed. Allen et al 7 defined nonutilization as an IV line not used for fluid bolus administration or medicines and found a 22% "nonutilization" rate amongst the 802 patients transported by ambulance in their system. In a

Total number of patients n= 290

FIGURE. Summary of study patients and paramedic decisions.

iV initiated by EMS n=165

IV not used by EMS or within 60 minutes of ED arrival n=84 29% OVER-TREATMENT

No iV initiated by EMS n= 125

I J

I

IV initiated and used in ED n=7 2% UNDER-TREATMENT

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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 17, Number 6 • October 1999

TABLE2. Patient Demographics

Characteristic (N = 290)

IV Placed Overtreatment (n = 84)

IV Placed Appropriate (n = 81)

No IV Placed Appropriate (n = 118)

No IV Placed Undertreatment (n = 7)

Age in years (mean -+ SD) % Female Pediatric (< 16 years) (%) Major trauma (%) Minor trauma (%) Medical (%) Chest pain Other medical Transport time (min) (median, interquartile %)

59.4 _+ 23.8 59 2.4 3.6 10 85 15 69 11 (7, 20)

55.1 +_ 23.8 58 2.5 1.2 10 86 19 62 11 (7, 15)

53.0 + 25.9 63 5.9 0 55 38 0 118 10 (6, 16)

49.2 _+ 28.6 71 14.3 0 29 57 0 7 9 (3, 10)

retrospective study, Donovan et al4 looked at prolongation of on-scene times by ALS procedures and found only 21% (10 of 47) of patients with an EMS initiated IV (by EMT intermediates who were not authorized the use of IV medicines) had the IV used within the first 10 minutes of the ED stay. This suggests that 4 of 5 patients could have safely waited for ED arrival before an IV treatment was initiated. Overtreatment at 29% (this report), 56% (Gausche et a16), and 22% (Allen et al 7) suggests that unused EMS IV placement occurs frequently. These studies were retrospective and thereby limited in their ability to evaluate necessity as it would be properly defined by patient outcome. We chose to define appropriateness based on actual use. Most would agree that if an IV line is used for fluids or medicines, its placement was appropriate. Although this definition may be criticized, variability in opinions regarding what constitutes "appropriate" IV placement are so great as to make other approaches untenable. Consideration was given to utilizing an expert panel to determine appropriateness, but the accuracy of this procedure is debatable, and others have experienced difficulties (personal communication, Baxter Larmon at UCLA-Prehospital Care Research Forum, 1997). A concern with our method of determining appropriateness, which is based on actual use, is the patient who presents with chest pain suggestive of myocardial ischemia but who does not need immediate IV treatments. Looking specifically at this group, IV lines were placed in 34 patients with chest pain suggestive of ischemia. Nineteen of these 34 cases were given fluid bolus or medicines in the IV, thus being categorized as appropriate. Fifteen of these 34 chest pain cases had an IV initiated but not used and were included in the overtreatment group. Some would argue that any patient with chest pain should receive an IV placement; however, only 4 of these 15 were admitted to the hospital, whereas 17 of the 19 chest pain cases in the appropriate group were admitted. This evidence supports our method of defining appropriateness of IV placement based on actual use of the IV line, although we concede that in some cases IV placement is "appropriate" even if not actually used. Comparisons may be made to clinical practice guidelines; however, no uniform national guidelines exist for when EMS should initiate an IV. The American College of Emergency Physicians Chest Pain Policy calls for an IV as a rule when the history shows "severe and crushing and

substernal" chest pain, when it is "tearing, severe, and radiating to the back," when the patient is cyanotic, and when differential upper extremity blood pressures exist37 Applying these criteria to EMS is difficult, because they have not been trained according to this approach. Of our 34 chest pain patients, only 2 met these criteria for IV initiation. Luterman et alia call in 1982 for clearer guidelines and a revision to paramedic training curricula to curb the problem of overuse of ALS skills has not been heeded.18 The dogma of basic paramedic education calls for IV placement for a variety of chief complaints without discerning the likelihood of actual need for an IV. 19Although some amount of overtreatment is expected, our results suggest that 1 of every 2 IV lines started in the field is not used. Moreover, the act of initiating an EMS IV is not innocuous. Pain inflicted on the patient, occupational exposure to bloodborne pathogens, 2°,21 and the incidence of catheterrelated infections ranging from 0.12% to 34% 15,16 are problematic. Costs and patient charges are needlessly increased when unused IV lines are placed. 6 The simple act of initiating an IV can change an otherwise basic life support (BLS) base rate into an ALS base rate, effectively doubling the patient charges. The only predictor of unused IV placement (overtreatment) was the presence of a paramedic student. Our EMS system is active in educating paramedic students. Because of the lack of validated guidelines for who should receive an EMS IV, borderline patients may receive IV lines for the sake of training. We are unaware of any studies that address the extent of unnecessary procedures performed on patients to allow for paramedic student training. Unused IVs have been demonstrated in hospital. Lederle et a122 showed that 35% of IVs had 2 or more consecutive days of idle use in their teaching hospital. We also hypothesized that more unused placements would occur when the paramedic experience level was less than 2 years, because they have not developed clinical sophistication. We did not find support for this hypothesis. Most paramedics at the study institution have practiced more than 2 years. Further study would need to be done to determine the true effect of paramedic experience level on IV placement decision making. Similarly, there was no apparent effect on IV overtreatment by transport time. We acknowledge limitations in this study. First, the definition of what constitutes "appropriate IV placement" is

PACE ET AL • PARAMEDIC DECISIONS AND IV LINES

difficult. Second, we were unable to demonstrate a difference between the subgroups looking at transport times and paramedic experience. The a priori power analysis was conducted specifically to test the hypothesis that a greater than 10% unused IV placement rate (overtreatment) existed. Although the primary hypothesis was supported along with a small association with respect to the presence of a paramedic student, the fact that we were unable to show a difference with transport times in excess of l0 minutes and when the paramedic experience level was less than 2 years may have been the result of small group size and a type II error, although this is unlikely given the narrow confidence intervals for these subgroups. Third, the low number of pediatric and major trauma patients may result in a sampling bias. Patients were selected if they were transported to either of 2 local emergency department receiving centers. Both facilities serve as on-line medical control base stations. These facilities were chosen because most of the EMS agency's ALS patients were transported to 1 of these facilities. In our system, pediatric and major trauma patients are most often transported by ambulance to the pediatric hospital or flown by helicopter to the trauma center. Neither of these centers were used in this study. In summary, we found paramedics exercised reasonable judgment and appropriate decision making when deciding to initiate an IV line in this primarily suburban EMS system with standing orders. The 29% nonuse rate and the 2.4% undertreatment rate may reflect the appropriate tradeoff between caution for potential patient deterioration and the minor complications and inconvenience of IV overtreatment. Perhaps a large incidence of nonuse is necessary to insure that all potentially unstable patients have ready IV. The presence of a paramedic student slightly increased the odds of overtreatment. Future directions should lead to decreasing the overtreatment rate without increasing the number of patients not treated with an IV line when needed. The authors thank Elizabeth Pulos, PhD, for her suggestions and expertise in statistical consulting, and Robert Lutz, MD, for his support.

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