Vascular Access Decisions in the Emergency Department; A tale of three types of failure. Results from an observational clinical trial.

Dr Peter Carr2
1Griffith University , Gold Coast , Australia, 2University of Western Australia, Perth, Australia

Introduction: “Ever tried. Ever failed. No matter. Try again. Fail again. Fail better.” A systematic scoping review of the literature for tools, rules and algorithms (TRA) for the insertion of the peripheral intravenous catheter (PIVC) identifies a clinically significant gap in the literature.
Aim:  To develop three  TRAs to “fail better” with PIVCs in the Emergency Department. Firstly, to promote appropriate PIVC insertion; secondly, to obtain first time PIVC insertion success; and thirdly to reduce post insertion failure rates.
Methods:  We performed data analysis using multivariate logistic regression modelling on prospectively acquired observations from an ED cohort.
Results: We observed 1,201 PIVC insertions in 879 patients.
Pre-insertion: A clinically indicated PIVC model that includes needing clinical procedures and infusates; likelihood of use >80%;  displays an area under the receiver operating characteristic curve of 0.81 and at the best cut-off the model yields a specificity of 0.81, sensitivity of 0.71 a positive predictive value of 0.89 and negative predictive value of 0.57.
Insertion: Factors shown to be independently associated with FTIS were decreasing age, adjusted odd ratio (OR) for success, for each 10-year decrease = 1.26 (95% confidence interval (CI), 0.92, 1.73); palpable vein without tourniquet, OR = 1.91 (95% CI, 1.37-2.67); an experienced clinician, with over 300 PIVC insertions, OR = 1.65 (1.17-2.31); and, confidence of clinician (80% + /100%), OR = 2.17 (95% CI, 1.58-2.98). The area under the curve, of the final model’s receiver operator characteristic was 0.67, and has been presented as a nomogram.
Post insertion: Infiltration and occlusion account for most failure (46%), but is less likely when an aseptic non touch technique (ANTT) is used is (HR 0.63, 95% CI 0.42-0.96).
Discussion: Clinician, patient, product and technology factors influence PIVC outcomes. Human factors surrounding appropriate device placement, in addition to strategies to improve insertion success along with identifying the mechanistic causes of post insertion failure require further scientific investigation. Our novel TRA for pre-insertion; insertion and post insertion outcomes requires external validation.

Pete Carr is a Senior Lecturer in the School of Nursing & Midwifery, Griffith University Menzies Health Institute Queensland, and key opinion leader in vascular access. His research focuses on vascular access outcomes in the Emergency Department including improving appropriate device selection; first attempt insertion success; and reducing post insertion failure. He is the lead author for the Cochrane review title for vascular access teams for device insertion and prevention of failure. He is a collaborator and principal investigator on the One Million Global Catheter study. He is also a vascular access clinician and has considerable expertise in ultrasound-guided peripheral and central intravenous catheter  assessment and insertion. He is faculty member for the World Congress on Vascular Access (WoCoVA). You can follow him on Twitter @pcarriv