Field Start IV policy

[HamsterRN]

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?

[HamsterRN, ADN, RN]

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?

I noticed the same thing when I was looking through the studies since searching "prehospital intravenous access" mainly gives you a whole bunch of studies that question the placement of pre-hospital IV's and the benefit of pre-hospital IV fluids and medications.

Our local EMS is pretty responsible about when to put in IV's, I typically only see them with major trauma, STEMI's, code/pre-code while en route, and with our Medflight that brings in cath codes from 600 miles away, which is 3 hours plus even with a good tail wind and usually have heparin/integrilin/NTG running while en route. Our local EMS has made a major effort in the past few years to focus more on "scoop and run" rather than "stay and play".

Our communication with local EMS is very good since our ED medical director is also the county EMS medical director. We have two EMS districts (City and County) but they all go through the same training and operate under the same policies and standards. The unification of my County's EMS was one of the medical director's big goals when he started and I realize not everyone area is this lucky, particularly 30 in one county seems like it could get unruly. Paramedics and EMT's get all of their IV, intubation, etc. training in our hospital. I don't doubt there are places where IV's are still put in often for the heck of it, particularly with such a decentralized system as you described.

[IVRUS, BSN, RN]

I encourage my students to remove and replace within the first 24 hours after its placement in a "non-traditional" setting. I think that this is wise as an EMT or paramedic who places the line in field, places it in less than ideal situations and will use less than ideal techniques. I understand that though intent is good, what will it benefit a person to have the line placed using perfect technique if that person ends up dying from their injuries which could have been circumvented if they received the IV meds needed in a more timely fashion. Did that emergency medical person scrub the skin for 30 seconds before placement of the catheter? No. Did that emergency medical person place the smallest gauge IV catheter for the prescribed therapy? No, they likely placed the largest IV catheter they could - It's a trauma situation. Therefore, site infections, and phlebitis will be more prevelant.

[HamsterRN, ADN, RN]

I encourage my students to remove and replace within the first 24 hours after its placement in a "non-traditional" setting. I think that this is wise as an EMT or paramedic who places the line in field, places it in less than ideal situations and will use less than ideal techniques. I understand that though intent is good, what will it benefit a person to have the line placed using perfect technique if that person ends up dying from their injuries which could have been circumvented if they received the IV meds needed in a more timely fashion. Did that emergency medical person scrub the skin for 30 seconds before placement of the catheter? No. Did that emergency medical person place the smallest gauge IV catheter for the prescribed therapy? No, they likely placed the largest IV catheter they could - It's a trauma situation. Therefore, site infections, and phlebitis will be more prevelant.

It appears that there once was a time where EMS practitioners did not practice IV insertions to the same level as hospital based providers, and this may still be the case in some areas. In my area, both groups practice to the same "best practice" standards, although if anything EMS exceeds best practice more than hospital providers in terms of policy, standards, training, equipment, and evaluation.

The outside world is not an ideal environment, but in terms of risk of infection, the hospital is far worse; a patient in an ambulance doesn't have to worry that the person placing their IV was elbow deep in diarrhea 3 minutes ago, but they do in the hospital.

I have never seen an RN scrub an IV site for 30 seconds prior to placing an IV, never.

There is no evidence that patient outcomes improve by the time saved in skipping aseptic technique, which is why our local EMS does not place a single "dirty" IV, regardless of the patient's condition. There is even questionable evidence that patient's benefit from pre-hospital IV's in general.

While 14-16 gauge used to be standard for EMS IV's, I now see mostly 20's and occasionally an 18 which are the same sizes that would be placed in the ED or on the floor. I don't really see 16's anymore in the case of trauma, if a gauge larger than 18 is needed then they usually have IO access.

There is significant evidence (1,280 field starts total studied) that there is not an increased risk of complications in pre-hospital IV's, at least 430 of these were trauma patients. The only study to suggest an increased risk in field starts was of 82 IV's from 1988, the circumstances of which have little relevance to current practice in my local area.

The practice of replacing pre-hospital IV's immediately, simply because it was placed prior to the hospital, is not evidence based practice, and in light of the evidence and rationale to the contrary, it is essentially myth based practice. If you're going to stick a foreign object into a patient, you should probably have a good reason.

[IVRUS, BSN, RN]

It appears that there once was a time where EMS practitioners did not practice IV insertions to the same level as hospital based providers, and this may still be the case in some areas. In my area, both groups practice to the same "best practice" standards, although if anything EMS exceeds best practice more than hospital providers in terms of policy, standards, training, equipment, and evaluation.

The outside world is not an ideal environment, but in terms of risk of infection, the hospital is far worse; a patient in an ambulance doesn't have to worry that the person placing their IV was elbow deep in diarrhea 3 minutes ago, but they do in the hospital.

I have never seen an RN scrub an IV site for 30 seconds prior to placing an IV, never.

There is no evidence that patient outcomes improve by the time saved in skipping aseptic technique, which is why our local EMS does not place a single "dirty" IV, regardless of the patient's condition. There is even questionable evidence that patient's benefit from pre-hospital IV's in general.

While 14-16 gauge used to be standard for EMS IV's, I now see mostly 20's and occasionally an 18 which are the same sizes that would be placed in the ED or on the floor. I don't really see 16's anymore in the case of trauma, if a gauge larger than 18 is needed then they usually have IO access.

There is significant evidence (1,280 field starts total studied) that there is not an increased risk of complications in pre-hospital IV's, at least 430 of these were trauma patients. The only study to suggest an increased risk in field starts was of 82 IV's from 1988, the circumstances of which have little relevance to current practice in my local area.

The practice of replacing pre-hospital IV's immediately, simply because it was placed prior to the hospital, is not evidence based practice, and in light of the evidence and rationale to the contrary, it is essentially myth based practice. If you're going to stick a foreign object into a patient, you should probably have a good reason.

Wow,

You say that you've never seen a nurse scrub the site for 30 seconds... Hmmm. That's Best practice in my world. Since 80 % of the bacteria are in the first five layers of the epidermis, without an adequate scrub, what are you dragging into the vascular system? The fact that it isn't your practice, makes me wonder what your EMT's are doing, but, we can agree to disagree, as usual.

[HamsterRN, ADN, RN]

I think you missed my point; nurses are hardly perfect in their compliance so assuming that a nurse placed IV is safer than a EMS placed IV is naive. For most floor nurses, 30 seconds seems like an eternity, spending the same amount of time scrubbing a site that we may spend eating a meal is unlikely, I'm not saying it's right, but decisions like these need to be based on the factors that are actually involved not what we wish they were.

[IVRUS, BSN, RN]

I think you missed my point; nurses are hardly perfect in their compliance so assuming that a nurse placed IV is safer than a EMS placed IV is naive. For most floor nurses, 30 seconds seems like an eternity, spending the same amount of time scrubbing a site that we may spend eating a meal is unlikely, I'm not saying it's right, but decisions like these need to be based on the factors that are actually involved not what we wish they were.

Well, All I have to say to that is...Have you ever heard of the saying " Chew each mouthful 20 times" LOL.. Maybe we could get better digestion if "we" didn't eat in 30 seconds!

And yes, compliance can be an issue, but I find that most of the time, if the nurse understands the rationale for doing something the right way, rather than "that's just how it's done" compliance is better and outcomes prove it.

[HamsterRN, ADN, RN]

We've made attempts to educate, although it's not as cut and dry as you make it seem. There is no single best practice recommendation, and the typical sources (the CDC and Joanna Briggs) say to scrub for the site for amount of time recommended by the manufacturer of your CHG, our supplier makes no recommendation other than to allow it dry for 30 seconds.

The total body of evidence is conflicting on this topic. While it was once thought that bacteria was the primary cause of phlebitis, it is becoming apparent that of the three types of phlebitis (mechanical, chemical, and bacterial), bacterial is actually the least common cause with peripheral IV's, which raises concern about potential mechanical damage to the vein caused by excessive scrubbing which may actually increase overall phlebitis rates.

Education is easier when there are straightforward answers backed by solid numbers, unfortunately that's not the case here.

We also used to be sure that frequent tubing changes would decreased the chance of infection although we didn't have a lot of data to support this. As more and more studies were done, it turned out that if anything it may increase the risk.

[GreyGull]

Unfortunately, aseptic and clean technique often get blended and are open for interpretation especially when not specifically spelled out. Unlike many hospital P&Ps, EMS protocols can be written vague in some areas and then spelled out clear in other areas which should be obvious. Even for the EMS agencies that do central lines in the field, if it states "alcohol pad", one alcohol pad is what is used. I have asked EMS agencies about their technique and as long as they use one alcohol pad and go from in to out with a circular motion the site is ready. Yeah, those central lines are removed as soon as other access is obtained and hopefully not too many attempts at different sites were done.

Some protocol examples of services that do central lines:

http://www.co.thurston.wa.us/medic1/images/2007%20Thurston%20County%20EMS%20Protocols.pdf

http://internet.lee-ems.com/intranet/ems/pub/doc/medical_guidelines.pdf

There are also many IV training videos on the internet by reputable EMS schools and agencies that demonstrate haphazard technique as well as some good. There have also been several TV EMS documentaries and reality shows that can make one cringe and not for the injuries caused by the accident. So, it is difficult to say all EMS agencies and providers within them are equally trained or aware of technique. Of course this can be said for hospital personnel as well. But in the hospital, we are made aware of our infection rate almost daily and it is expected to report less then good technique by any professional including physicians. It seems like for some procedures there are 2 - 3 people assigned to document the quality of your technique especially in the ED and the ICUs. With the emphasis on infection control and CMS, I am surprised that some hospitals are not adopting a closer oversight for technique.

[GreyGull]

We also used to be sure that frequent tubing changes would decreased the chance of infection although we didn't have a lot of data to support this. As more and more studies were done, it turned out that if anything it may increase the risk.

That is interesting. In our ICUs, RTs used to change the ventilator circuits q48 hours and the inline suctions q24 hours. Now, the circuits are once a week (with most pts being extubated by then) and the inlines are q72 hours.

[Rexie68]

I only know that 90-95% of our EMS pts come in with an IV...never smaller than a 20 gauge and usually an 18 gauge and most likely in the AC or hand. We change them within 48 hours....if they last that long. Even if the site was placed in another hospital, we change it within 48 hours since we're now responsible for that site. Also, if we place an IV emergently we also replace it ASAP since asceptic technique isn't our top priority when someone is crashing.