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Base hos- pital written records and taped patient calls were re- ... Medical Center, 1000 West Carson Street, Box 21, Torrance, ... 200,000 call to 911 per year.
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OUT-OF-HOSPITAL IV ACCESS

Out-of-hospital Intravenous Access: Unnecessary Procedures and Excessive Cost MARIANNE GAUSCHE,MD, RICHARD E. TADEO, RN, MARTHA C. ZANE, RN, ROGER J. LEWIS, MD, PHD Abstract. Objective: To evaluate the concordance with criteria developed by the study investigators and supply costs associated with placement of IV lines and saline locks by paramedics in the out-of-hospital setting. Methods: This was a retrospective consecutive case series a t a n urban base hospital. Patients were treated by paramedics using one base hospital for medical control during December 1995.Base hospital written records and taped patient calls were reviewed to determine actual IV access method used by paramedics, chief complaint, and whether fluid administration was ordered. Indicated method of IV access was determined for each patient based on predetermined criteria developed by the investigators. IV access methods were ranked by cost of supplies as follows: IV line (IV)> saline lock (SL) > no IV line (NOW). An assignment of concordant treatment was made when actual = indicated method, discordant-overtreatment when actual > indicated, and discordant-undertreatment when actual < indicated. Results: 452 patients were treated via radio by the base hospital during the study period. 380 of 452 (84%) received a n W.28 of 380 (7%) received fluid resuscitation in the field. 166 of 452 (37%) received concordant treatment; 253

I

NTEGRAL to the scope of practice of the paramedic is establishment of vascular access and fluid resu~citation.l-~ Methods to achieve vascular access include peripheral vein cannulation with a n IV catheter and intraosseous line placement (children). IV access may then be supported with a saline lock (SL) or with a n IV line connected to fluid (IV). Although time t o IV line placement, success rates by age, complication rates, and effect on scene time have been there are no

(56%) discordant-overtreatment; and 33 (7%) discordant-undertreatment. Pediatric patients (514 years of age) were more likely to be undertreated a s compared with adults, 33% vs 3% ( p c 0.001). Patients who had medical chief complaints were more likely to receive discordant-overtreatment as compared with patients who had trauma chief complaints, 61% vs 32% ( p e 0.001).73% of chest pain patients received discordant-overtreatment. Based on these data, the yearly cost of supplies used in IV access discordant-overtreatment was $13,736 for this base hospital and $560,000 for the Los Angeles County emergency medical services (EMS) system. 91% of the excess supply cost is due to patients' receiving a n IV instead of a SL. Conclusion: Based on study criteria for utilization of IV lines vs SLs in the field, paramedics and base hospital personnel often provide discordant-overtreatment of patients by placement of a n IV when a SL or N o N would suffice, resulting in unnecessary costs for EMS systems. Key words: emergency medical services; prehospital; intravenous; appropriateness; cost. ACADEMIC EMERGENCY MEDICINE 1998;5~878-882

widely accepted criteria to decide which patients in the out-of-hospital setting require a n IV,which require a SL, and which require no venous access (NoIV). It is also not clear whether the development of such criteria would result i n a cost reduction within emergency medical services (EMS)systems. In 1994, Boyle and Kuntz described the use of SL and IV by paramedics treating 100 patients in a n urban EMS system.8 The SL was used by paramedics to obtain IV access on patients who did not From the Department of Emergency Medicine, UCLA School require fluid resuscitation in the field. Advantages of Medicine, Harbor-UCLA Medical Center, Torrance, CA of placement of the SL vs a traditional IV included: (MG, RJL); the Department of Health Services, Los Angeles 1) SL placement was easier and better tolerated by County Emergency Medical Services Agency, City of Com- patients; and 2)SL placement provided a cost savmerce, CA (RET); and the Department of Nursing, Harborings to the hospital and the patients. Specific UCLA Medical Center, Torrance, CA (MCZ). Received December 5, 1997; revision received April 6, 1998; guidelines for placement of a SL or an IV, or the accepted April 25, 1998. Presented at the SAEM annual meet- appropriateness of each technique, were not ining, Washington, DC, May 1997. cluded, however. Address for correspondence and reprints: Marianne Gausche, The objectives of this study were: 1) to develop MD, Department of Emergency Medicine, Harbor-UCLA for the utilization of SL and IV placement criteria Medical Center, 1000 West Carson Street, Box 21, Torrance, CA 90509-2910. Fax: 310-782-1763; e-mail: mgauschea for patients treated in the out-of-hospital setting; ernedharbor.edu 2) to describe actual paramedic practice in rela-

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tionship to placement of IV lines; 3) to then apply the previously developed criteria for SL and IV placement to these cases of paramedic practice to determine concordance of IV access techniques for each patient; and 4) to estimate discordant-overtreatment supply costs for the base hospital and the EMS system.

TABLE 1. Study Criteria for N Line (IV)and Saline Lock (SL) Placement in the Out-of-hospital Setting ~

IV line ifc: 1. Any chief complaint with signs or symptoms of shock: SBP 190 mm Hg (children 570 mm Hg)

HR 2120 or 4 0 beatdmin Weak, thready pulse Cold, clammy extremities Disorientation

METHODS

or

Studu Design. This was a retrospective study of a consecutive case series of patients treated by paramedics using one base hospital for medical control. Indicated methods for IV access were compared to actual methods, and a cost assessment with actual practice was done. This study was approved by the institutional review board a t Harbor-UCLA Medical Center.

2. Any mandatory trauma triage criteria: 0 0 0

0 0

0 0

Setting and Population. This study was conducted at Harbor-UCLA Medical Center in Torrance, California. Harbor-UCLA Medical Center is a n urban county hospital, a Level-1 trauma center, a pediatric critical care center, and a base hospital. The base hospital averages 450 medical control calls per month. Harbor-UCLA Medical Center is one of 23 base hospitals in the Los Angeles County EMS system. The Los Angeles County EMS system receives approximately 200,000 call to 911 per year. Study Protocol. Both IV line placement and SL placement were in the scope of practice of paramedics during the study period, and the decision for which method to use, if any, was based on the judgment of base hospital personnel or the paramedic treating the patient. No established criteria for the use of one technique or the other were in place; however, out-of-hospital treatment protocols were in place specifying which patients should be considered for fluid resuscitation or medication adm i n i s t r a t i ~ n . ~The . ’ ~ investigators developed criteria for placement of a n IV and a SL for patients in the out-of-hospital setting, using local treatment policies currently in place in Los Angeles County (Table lh9Criteria for IV were based on the presence of shock or being in extremis, the need for fluid resuscitation (as per out-of-hospital treatment guidelines),’O or the potential for rapid deterioration of the patient. Criteria for SL were based on the possible need for IV medications and the need to establish a “lifeline” in case of a change in the physiologic status of the patient. An assignment of NoIV was made when the patient did not qualify for either a n IV or a SL. Validation of these criteria based on the subsequent fluid resuscitation in the ED was not attempted. Using ED fluid resuscitation as a “crite-

0 0 0 0

Adults with SBP < 90 mm Hg Children with SBP < 70 mm Hg Abnormal capillary refill No spontaneous eye opening Penetrating cranial injury Penetrating thoracic injury between the midclavieular lines Gunshot wound to the trunk Blunt injury to the chest with an unstable chest wall (flail chest) Penetrating injury to the neck Diffuse abdominal tenderness Patients surviving fall >15 feet Intrusion of the motor vehicle into the passenger space Patients in cardiopulmonary arrest with penetrating torso trauma or

3. Second- or third-degree burns

>lo% of body surface area

0

SL if no indication for IV and*: 1. No signdsymptoms of shock and any chief complaint of: Chest pain Palpitations Dysrhythmia and patient >35 years of age or 2. Any chief complaint of:

Altered level of consciousness Syncope Seizure Weakness and dizziness Nausea and vomiting Gastrointestinal bleeding Vaginal bleeding Labor Allergic reaction with shortness of breath Overdose or

3. Any trauma triage guidelines: Surviving victims of vehicular collisions in which fatalities occur Pedestrians struck by automobiles Patients ejected from vehicles Patients requiring extrication Very young and very old patients and those with precarious medical histories

*Any patient without an indication for an N or a SL was assigned to the NOW category, meaning vascular access was not indicated. SBP = systolic blood pressure; HR = heart rate.

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TABLE2. Chief Complaints of Out-of-hospital Patient Calls to an Urban Base Hospital Chief Complaint

Frequency Percentage

Medical Shortness of breath Altered level of consciousness Chest pain Seizure Weak and dizzy Poisoningloverdose Syncope Other medical (allergic reaction, foreign body aspiration, palpitations, nausea and vomiting, labor, abdominal pain, headache) Trauma Motor vehicle crash Motorcycle crash Gunshot wound Fall Stab wound Burn Traumatic cardiopulmonary arrest Other trauma

TOTAL

95 76 62 54 25 10 10

39

21.0% 16.6% 13.7% 11.9% 6.6% 2.2% 2.2% 8.6%

6.2% 3.8% 3.1% 1.8% 1.5%

28 17 14 8

7 2 2

0.4%

14

3.1%

462

100.0%

0.4%

rion standard” for the need for IV line placement could be problematic because the patient’s status may change from the field setting en route to the hospital, and further assessment and use of diagnostics in the ED may then determine that fluid is or is not indicated. Therefore, criteria for concordance of IV techniques used by the paramedic were based solely on the out-of-hospital presentation of the patient.

OUT-OF-HOSPITAL lV ACCESS

Measurements and D&nitions. Base hospital recordings and accompanying written base hospital records from the month of December 1995 were reviewed to determine the IV access method indicated. Two investigators (RET and MCZ) determined the indicated method for each patient; a third investigator (MG) was used for determination of indicated method if there was disagreement in indicated method. The 2 investigators agreed on the assignment of indicated method in 4451452 (98%)of the cases, and the third investigator (MG) determined the assignment on the remaining 7 cases (1.5%). Actual IV method used by paramedics, the age of each patient, whether fluid administration was ordered, and the amount of fluid ordered by base hospital personnel were also recorded. Intravenous access methods were ranked according to cost as follows: N > SL > NoN. An assignment of concordant treatment was made when the actual method was the same as the indicated method; a n assignment of discordantovertreatment was made when the actual method was greater than the indicated method, for example, when a n IV line was placed by paramedics and a SL or NoIV was indicated; and a n assignment of discordant-undertreatment was made when the actual method was less than the indicated method, for example, when a SL or NoIV was placed and an IV was indicated. The supply costs of N and SL were determined by summing the costs of materials used for each of the 2 vascular access methods. For an IV, these costs included 1 liter of normal saline, IV tubing, a stock N line kit, and a n 18-gauge catheter, for a total of $8.60. The costs for a SL included a saline

100 90 C

a z, m

rc 0

a!

CJI

80 70

Discordant-Over

60 50

2 40 C

2a

2

30 20 10

0

SOB (n = 95)

CP (n = 62)

Seizure (n = 54)

ALOC (n = 75)

GSWlSW (n = 21)

MVClMCC (n = 45)

Chief Complaint FfQure 1. Concordance of actual vs indicated IV access technique by chief complaint. SOB = shortness of breath; CP = chest pain; ALOC = altered level of consciousness; GSW/SW = gunshot woundlstab wound; MVC/MCC =

motor vehicle crasldmotorcycle crash.

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lock, saline flush, a 3-mL syringe with needle, a n 18-gauge catheter, and a stock IV line kit, for a total of $4.37. Actual patient charges, which may be much higher, were not calculated.

Data Analysis. Descriptive statistics were used to define univariate characteristics of the population and to determine frequencies of vascular access methods used. The x2 test was used to compare the frequencies of concordant treatment, discordant-overtreatment, and discordant-undertreatment by age category ( 2 1 5 years vs 5 1 4 years), chief complaints, and the frequencies of fluid administration. The Wilcoxon rank sum test was used to compare the age distributions of patient groups. A p-value of ~0.05was considered significant. Costs of discordant-overtreatment were calculated by subtracting the supply costs of indicated method from the supply costs of actual method. Undertreatment costs, such as the cost of added morbidity when a n IV was not placed and one was indicated, were not estimated.

RESULTS During the l-month study period, there were 452 base hospital medical control calls. The mean patient age was 49 ? 26 years (range 0-101 years). Fifty-nine percent of the patients were male and 41% female. A total of 380 of 452 (84%)of the patients received a n IV, 63 of 452 (14%) received NoIV, and 9 of 452 (2%)received a SL. Chief complaints for patient calls are listed in Table 2. Medical chief complaints predominated (84%), and trauma chief complaints comprised a minority of calls (16%). Only 28 of 380 patients (7.4%)who received IV also received fluid resuscitation in the field. Of patients with medical chief complaints, 314 (83%)actually received a n IV, 56 (15%) received NoIV, and 9 (2%) received a SL, whereas an IV was indicated, as determined by the investigators, in 90 (24%) patients, NoIV in 44 (12%), and SL in 245 (65%). Of patients with trauma chief complaints, 66 (90%)received a n IV, 7 (10%) received NoIV, and none received a SL, whereas an IV was indicated in 47 (64%),NoIV in 4 (5%), and SL in 22 (30%).Differences in actual IV method by chief complaint (medical and trauma) were not significant ( p = 0.072);however, differences in indicated method by chief complaint were significant ( p = 0.001). Based on their out-of-hospital presentation, 166 of 452 (37%) of the patients received concordant treatment with that determined by study investigators; 253 of 452 (56%) received discordantovertreatment; and 33 of 452 (7%) received discordant-undertreatment. The most common chief complaints and the concordance in treatment

-

0Discordant-Under u

.-c d

60

Concordant Discordant-Over

50

;

'c

40

m

E 30 0

2 20 0

R

10

0 Children (n = 57)

Adults

(n = 395)

Age Group Ffaure 2. Concordance of actual vs indicated IV access technique by age group.

received are illustrated in Figure 1. Patients with a medical chief complaint were significantly more likely to receive discordant-overtreatment as compared with trauma patients, 61% vs 32% ( p < 0.001). Patients with a medical chief complaint were also significantly older (mean age 52 2 25 years) than trauma patients (mean age 33 2 19 years) ( p = 0.0001). Seventy-three percent of the 62 patients with a chief complaint of chest pain received discordant-overtreatment, whereas only 20%of the 45 patients with a motor vehicle or motorcycle crash received discordant-overtreatment. Patterns of appropriateness of treatment by age group are illustrated i n Figure 2. Pediatric patients (514 years) were significantly more likely to receive discordant-undertreatment as compared with adult patients, 33.3%vs 3.1% ( p c 0.001). Of the 395 adult patients, 361 (91%)received a n IV, 25 (6%)received NoIV, and 9 (2%)received a SL, whereas a n IV was indicated in 123 (31%),NoIV in 28 (7%),and SL in 244 (62%).Of the 57 pediatric patients, 19 (33%) received a n IV, 38 (67%) received NoIV, and none received a SL, whereas a n IV was indicated in 14 (25%), NoIV in 20 (35%), and SL in 23 (40%).Differences in actual and indicated treatment by age class (adult and pediatric) were significant ( p = 0.001). The overall mean cost of IV access supplies per patient equaled $2.73; median cost equaled $4.23. Cost of IV access supplies per patient varied significantly by age class of patient (adult vs child$2.88 vs $1.23) and by chief complaint (medical vs trauma-$2.97 vs $1.471, p c 0.0001. The yearly cost of discordant IV access was $13,735 for this base hospital. Extrapolating these data to the Los Angeles EMS system as a whole, the yearly cost of discordant IV access would be $560,000 for this urban EMS system. Ninety-one

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percent of this cost is due to patients’ receiving an IV when a SL is indicated.

DISCUSSION Although EMS systems have been in existence for 28 years in the United States, critical analysis of the efficacy or appropriateness of many interventions performed by out-of-hospital providers has rarely occurred.11J2This study reviews 2 commonly accepted IV access methods for concordance of the method with criteria developed by the study investigators, and then determines the supply cost of discordant-overtreatment to a n individual base hospital and extrapolates this cost to a large urban EMS system. This study both confirms findings by other investigators and adds additional information about the differences in discordant-overtreatment and discordant-undertreatment by patient chief complaint and age.13 Based on protocols given to paramedics, Boyle and Kuntz found that paramedics chose the “correct” vascular method 100%of the time.sOur study showed quite a different result. When given no explicit criteria for when to use one method or the other, actual use of IV lines and SLs for IV access in the out-of-hospital setting matched with our determination of which technique was indicated in only 36% of patients. Utilization of one method vs the other was based on paramedic and base personnel judgment. It is clear from our results that without specific criteria for the use of each method, IV line placement is “preferred” by paramedics and base personnel, resulting in additional supply cost to the base hospital and to the EMS system. Previous emphasis on the use of IV lines and perceived differences in the difficulty of different IV assess skills may have had an effect on our results. Anecdotally, paramedics have reported to study investigators that they believe a n IV is easier to place than a SL. Boyle and Kuntz found no difference in the ease of placement of a n IV and a SL.S

LIMITATIONS AND FUTURE QUESTIONS The current study may be limited in its generalizability, because the data were collected a t a single base hospital; however, this base hospital has a moderate volume, on par with the volume of patients managed in many other EMS systems. The study, as designed, could not estimate the cost of morbidity associated with discordant-undertreatment. Determination of undertreatment costs is an important component of true cost analysis of a n intervention. This calculation, however, is difficult and requires consideration of future cost to the patient and hospital.

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OUT-OF-HOSPITAL IV ACCESS

Future questions include the prospective validation of these criteria, the frequency with which out-of-hospital personnel accurately follow such criteria, and further delineation of costs of overand undertreatment to patients and to the EMS systems.

CONCLUSIONS ‘Ib our knowledge, our study is the first to establish specific criteria for IV line and SL placement in the out-of-hospital setting, to determine the frequency and cost of discordant-overtreatment, and to evaluate these differences in use of IV access techniques by specific populations (adult and pediatric; medical and trauma) in a n urban EMS system. Emergency medical services systems should be encouraged to establish criteria or protocols for SL and IV use such as outlined in this study, because considerable cost savings could be achieved. The authors thank the Los Angeles County Emergency Medical Services Agency for their support of out-of-hospital research.

References 1. Bledsoe BE, Porter RS, Shade BR (eds). Brady Paramedic Emergency Care. Englewood Cliffs, NJ: Prentice-Hall, 1991. 2. Allison E J (ed). Advanced Life Support Skills. St. Louis, MO: Mosby-Year Book, 1994. 3. Hoffman SH, Dieckmann RA.Prehospital illnese treatment. In: Dieckmann RA (ed). Pediatric Emergency Care Systems: Planning and Management. Baltimore: Williams & Wilkins, 1992. 4. Pons PT, Moore EE, Cusick JM, Brunko M, Antuna B, Owens L. Prehospital venous access in a n urban paramedic system-prospective on-scene analysis. J Trauma. 1988; 28: 1460-3. 5. Lillis KA, Jaffe DM. Prehospital intravenous access in children. Ann Emerg Med. 1992: 21:1430-4. 6. Slovis CM, Herr EW, Londorf D, Little TD, Alexander BR, Guthmann RJ.Success rates for initiation of intravenous therapy en route by prehospital care providers. Am J Emerg Med. 1990;8~305-7. 7. Levine R, Spaite DW, Valenzuela TD, Criss EA, Wright AL, Meislin HW. Comparison of clinically significant infections among prehospital- versus in-hospital-initiated IV lines. Ann Emerg Med. 1995;25:502-6. 8. Boyle MF, Kuntz B. Saline locks in prehospital care. Prehosp Disaster Med. 1994;9:190-2. 9. Prehospital Care Policy Manual. Los Angeles: Department of Health Services, Los Angeles County Emergency Medical Services Agency, 1995. 10. Los Angeles County Base Hospital Treatment Guidelines. Los Angeles: Department of Health Services, Los Angeles County Emergency Medical Services Agency, 1992. 11. Page JO. Historical perspective on EMS systems. In: Roush WR (ed). Principles of EMS Systems, Dallas, Tx:American College of Emergency Physicians, 1994. 12. Gausche M. Differences in the out-of-hospital care of children and adults: more questions than answers. Ann Emerg Med. 1997;29:776-9. 13. Fuller FP, Pace SA, Lutz SA. Out-of-hospital initiated intravenous lines: are we starting too many? [abstract]. Ann Emerg Med. 1997;30:397.