Field Start IV policy

[HamsterRN, ADN, RN]

The replacement of pre-hospital IV's, or "field start" IV's, on arrival to a hospital was once common practice, but doesn't seem as commonly accepted as it once was. My hospital is currently reviewing it's policy on pre-hospital IV's. I know of one study from 1988 that showed some apparent risk to leaving them in, but more recent studies have suggested they are not riskier. Does anybody know of any other studies that suggest there is a risk in leaving field start's in place? Has anyone worked someplace in recent years that noticed any problems with leaving field starts in?

[Spritenurse1210, BSN, RN]

I've seen IVs that were started in the field and left in for 4 days or more, because no one else could get an IV on the person. I havent seen any infections as a result of a field start IV and often they are high quality IVs. I've always said, that if one can start and IV in the back of a speeding ambulance, then they have to be good! my 2 cents.

[diane227, LPN, RN]

I think the important things are 1. Assess the site 2. If site appears ok, clean and redress the IV site according to your hospital protocol, 3. Document on the IV site that it was a field start and the date started. 4. Continue to assess daily. We do not leave any IV in longer than 3 days. If the patient is a hard stick we can extend dwell the IV for a day but it has to be documented and the IV site must be assessed Q4 hours.

[ObtundedRN, BSN, RN]

I've never read any studies on it, but I used to work in EMS. Most of the time the IVs are started once the patient is in the back of the truck. Its rare that we started our IVs inside the home, or on the street corner, etc. When its done in the back of the truck, its pretty much the same as starting it inside the hospital. As long as the person starting the IV keeps their IV site cleaned properly, it should be just as good as a hospital start (which is just as dependent on the clinician cleaning the site).

[Esme12, ASN, BSN, RN]

In the settings of "hospital aquired" infections an not being reimbursed for line aquired infections a trend has developed to remove outside placed lines only after securing a new line and absolute removal of outside lined with in 48 hours.

[GreyGull]

Every EMS agency is different. Some like to stay and do all their interventions before moving the patient and some like to do the procedures enroute. Some FD Paramedics must load their patients into a contracted BLS truck where they do not have any control over the cleanliness in the back. If you have been involved in EMS you may have seen the recent studies that have appeared about cleaning ambulances which aren't flattering. The IV training and infection control education also varies since EMT-Basics, EMT-Intermediates and Paramedics, or whatever the credentials in your area, can all start IVs in some places and training may only be a couple of hours with few to no human starts. After that it depends on the service as to how many IV starts an EMS provider might do. Some may only do 1 per year while others might do 5 per day. Some services use EZ-IOs which eliminates the struggle for difficult IVs which had kept the need for the skill sharper. Sometimes the hospitals where the EMS clinicals are done can influence the education for IV starts, hopefully for the better. The "field way" as taught by some EMS instructors sometimes is not the best way since they stress a rapid start and will often tell the students that all the patients will get antibiotics to cover all possible infection. And then, there are some great programs where the instructors will teach above and beyond the course material. These instructors may also have RN credentials.

There are a few studies there but some were done just for trauma patients. Often at trauma centers a central line is also placed or another hospital IV (OR or ED) started which takes the burden off the field IV so there is less chance of phlebitis. Many EMS IVs are antecubitals and if a patient complains of discomfort, the IV is changed to maintain patency and comfort level before there is a chance for phlebitis to start.

Here is a recent study.

http://contentdm.lib.byu.edu/ETD/image/etd2009.pdf

However, note that it is done on trauma patients, which may lack pre-existing medically complex issues, and like some of the other studies, they list these limitations.

page 11

LIMITATIONS

Even though this pilot study provided new and helpful information regarding phlebitis rates in trauma patients, there are at least six limitations to the study. First, neither medication therapy nor how often intravenous tubing was monitored or changed was recorded. In addition, no bacterial catheter tip cultures were performed on those PIVCs that were removed. Four, the presence of underlying medical conditions in these trauma patients (blood dyscrasia or autoimmune disease) which may increase the incidence of phlebitis were not studied. Five, although patients were brought to the ED with multiple IV’s, only one IV per patient was used for analyzing the presence or absence of phlebitis. Finally, the study was limited to one geographical location.

It would be very difficult to make a blanket statement about all field IVs from that study or any of the other studies that have similar limitations. When you look at studies published, you should also look at the author and the intent of the study as to whether it is biased or if it is a grad student doing a thesis with limited resources. Personally I would not consider this a good study for agrument of either pro or con but it has been used in other discussions concerning field IVs. Also, if you look at the studies from other countries, remember the EMS providers may have the equivalent of a 4 year degree for education and some may be RNs with hospital experience.

We change out field IVs and any others started emergently, including in house emergencies, under less than ideal situations generally as soon as possible when alternative access is available or in 24 hours. 72 hours for all the others. Of course, we also have doctors and NPs or PAs who can do central lines and PICCs available 24/7. There are probably many hospitals that do not have these professionals around all the time who are comfortable with placing central lines or PICCs so you may have to work with what you got.

The hospital assumes responsibility for the IVs and any acquired infections. That part has been made very clear by CMS so many hospitals will lean to the side of caution.

If you want to do a more informative research for policy building, contact the infection control offices at several hospitals in different regions. They may also have the reasons why their policy exists as it does and the resources they used. Look at those which have a good mix of EMS providers to see how the policies vary. If you only have a single EMS provider, the policy may treat field starts as any other IV. If there are over 30 different EMS agencies with FD and private mix, there may be stricter control of the IVs. Also, contact a few different EMS agencies for their IV start policy, how competency is maintained and what infection control education is done. Several hospitals have also switched to using ChloraPrep (chlorhexidine gluconate) or some other product for their IV kits while EMS uses alcohol wipes. This may also influence policy.

Another article.

Journal of Trauma Nursing:

Peripheral Intravenous Catheters Started in Prehospital and Emergency Department Settings

April/June 2008 - Volume 15 - Issue 2 - p 47–52

http://journals.lww.com/journaloftraumanursing/Abstract/2008/04000/Peripheral_Intravenous_Catheters_Started_in.6.aspx

This one states the CDC recommends 48 hours.

[Rexie68]

i'm an iv team rn. we replace all pre-hospital iv's within 48 hours....even if they were placed in another hospital. we have a 24/7 iv team that can insert iv's with ultrasound guidance if needed and/or insert a picc, and our docs can put in a central line at any time. 98% of the time we can get you an iv and almost the same percentage of the time i can put in a picc. if you need access fast and we can't get it, the doc can do a femoral line. for ivs that are started in our hospital, we replace them every 96 hours and/or prn.

[mamamerlee, LPN]

Rexie - very hard to read your red post.

[Rexie68]

rexie - very hard to read your red post.

sorry!!

i'm an iv team rn. we replace all pre-hospital iv's within 48 hours....even if they were placed in another hospital. we have a 24/7 iv team that can insert iv's with ultrasound guidance if needed and/or insert a picc, and our docs can put in a central line at any time. 98% of the time we can get you an iv and almost the same percentage of the time i can put in a picc. if you need access fast and we can't get it, the doc can do a femoral line. for ivs that are started in our hospital, we replace them every 96 hours and/or prn.

[HamsterRN, ADN, RN]

I appreciate the responses, GreyGull in particular went above and beyond.

It's interesting that the issue of CMS reimbursement was brought up as a reason for changing out pre-hospital IV's since our concern is that changing them out unnecessarily actually may increase the chance of IV complications and therefore hospital liability.

There is no relevant data to suggest that pre-hospital PIV's are at an increased risk of complications. There is data that suggests that each IV start carries a risk of bacterial contamination and complications, which would imply that changing out IV's unnecessarily actually increases the odds of IV related complications with no reduction in risk to balance that out.

The 2002 CDC recommendation is that lines placed without aseptic technique be changed within 48 hours, although the data this is based on involves only central lines.

Lumping all pre-hospital starts into this group and assuming all pre-hospital IV starts were placed without aseptic technique or with questionable aseptic technique is a bit of a stretch since EMS practices and standards have changed significantly over the past 20 years, although I agree it would largely depend on the standards and practices of your local EMS. We have one EMS group that serves our hospital, their IV skills are taught in our hospital and they receive more thorough and comprehensive training than RN's. Their standards are also at least equal to if not more strict than within the hospital; they have no situations in which skipping aseptic technique is considered acceptable including cardiopulmonary arrest and major trauma. There equipment is identical except for their dressing and securement device which are superior to what we use in the hospital.

The two studies offered by GreyGull were the two current studies I was aware of as well. As with all studies, there were some limitations, although those limitations would have most likely skewed the results to show an artificially elevated frequency of complications in pre-hospital IV starts if they altered the results at all, yet neither study showed an increased risk in the 1,300 pre-hospital IV's studied, about half of which were trauma patients which are usually considered to be the high risk group.

I'm all for erring on the side of caution, but exposing patients to the harm and risk of unnecessary IV starts would seem to be erring on the side of potential harm. Although if your local EMS is not yet up to current standards then I agree it gets trickier.

[iluvivt, BSN, RN]

I say you need to assess these on a case by case basis. If the site is at an area of flexion or in a high risk area ,such as the wrist..I say change it....if it is a perfectly good site..asymptomatic...I say use it

[GreyGull]

i'm all for erring on the side of caution, but exposing patients to the harm and risk of unnecessary iv starts would seem to be erring on the side of potential harm.

what about the studies that have shown ems ivs to be started and never utilized? or, just started because they felt they had to because they are "als"? or, for billing purposes? or the emt-bs who start them because they can but are not able to do anything beyond that? how many are started just to get a paramedic that one field stick for the year? or, to allow students to practice and treatment by iv either prehospital or in the ed will not be necessary? how many attempts are too many? 2 per provider is the norm but how many providers? we may see 6 attempts and maybe the 4th provider is successful. but, there may only be 2 attempts documented which skews data collection. what about ivs being attempted because the prehospital providers are not trained to access long term existing devices?

granted the ed nurses may like to see an iv placed and may even expect it but are the reasons for starting an iv valid if it is not going to be utilized?

when are prehospital intravenous catheters used

for treatment?

http://www.co.sanmateo.ca.us/vgn/images/portal/cit_609/7/11/1358837790article_kas_prehospital_iv.pdf

an evaluation of an educational intervention to reduce inappropriate cannulation and improve cannulation technique by paramedics (uk)

http://emj.bmj.com/content/26/11/831.abstract

unnecessary intravenous access in the emergency setting

http://www.informaworld.com/smpp/content~db=all~content=a777750966

guidelines for prehospital fluid resuscitation in the injured patient

(the studies cited in this study are very interesting.)

https://secure.muhealth.org/~ed/students/articles/jtrauma_67_p0389.pdf

the time cost of prehospital intubation andintravenous access in trauma patients

http://informahealthcare.com/doi/abs/10.1080/10903120802096928

there are a lot of factors that vary even within each area and agency. if you have only one ems agency and good communication with them concerning their medical oversight and ongoing training, your policy may be very different from a hospital that has over 30 ems agencies or over 2500 paramedics in one large county system. also, the type of training programs and clinicals vary from city to city and the hours vary from state to state. attitudes also impact a region and the success of ems. was the paramedic cert mandatory to gain entry to a fd job? how many fds developed als ems quickly with little experience on the medical side and maybe even for the wrong reasons? again, each and every region is different. it is great to hear when one agency surpasses the standards of a hospital as in your example but that may not be the norm.