Need Help - Pre hospital vs in hospital leurs

[celticcare]

Ok, this is something of topical debate in where I work, primarilly me and a hand ful of other nurses against the rest regards prehospital IV insertion.

The general thought from nursing staff, is that EMS staff don't insert IV's sterily and their ability to clean an IV site doesnt exist. The policy where I work, is to remove the ambulance leur *which is patent, flushing and working and properlly inserted* and replace it with one that is inserted in hospital.

I have seen IV's being removed that were say a 18 g no problems, no signs of phlebitis and then the nurses can't get even a 20/22 g iv in and then HELLO, patient starts getting chest pain and requires morphine. *Yes I know stupid removing a leur before securing a new one, but hey this is what I have to work with*.

My question for you to help with, is there any articles, studies, policies, anything that shows that leurs inserted prehospitally have a lower infection rate than those in hospital? The nurses are adament that pre hospital leurs are far more dirtier than in hospital *they have this perception of paramedics not wearing gloves, just wiping some mud away and boom put it in* and are removing what could be patent and stable leurs. Our hospital policy is a leur is to remain in no longer than 72 hours before it is to be removed.

I want the evidence to basically go to my clinical supervisors and say, there's the evidence, personally I've been keeping a record of Iv's prehospitally vs in hospital and the in hospital inserted leurs, have more rates of mechanical phlebitis and also more rates of infection than pre hospital.

If anyone can help, I'd be grateful as I think this is personally, a stupid action that causes wastage, more pain for patients *seeing some nurses and junior doctors digging for ages when they pulled out a perfectly good ambulance leur* and opens up more risk of infection and honestly hasnt been thought out clear enough.

Scotty

Edited April 27, 2009 by celticcare

[JPINFV]

Comparison of clinically significant infection rates among prehospital-versus in-hospital-initiated i.v. lines.

STUDY OBJECTIVE: To compare the risk of infection for i.v. lines placed in the prehospital versus in the in-hospital setting in a midsized emergency medical service system. DESIGN: A retrospective analysis was made of all i.v. line site infections among patients admitted to ward beds from a university hospital emergency department in 1992. METHODS: The hospital's infection control team conducted daily ward rounds and a surveillance of all wound and blood cultures. Patients with signs and/or symptoms consistent with Centers for Disease Control and Prevention guidelines for skin and soft tissue infection were reported to the responsible medical team. Infections were documented based on consensus opinion between the infection control team and the physicians responsible for the care of the patient. IV lines placed in the prehospital phase of care were identified by electronic retrieval from the prehospital database. RESULTS: Three thousand one hundred eighty-five patients who had a prehospital or an in-hospital i.v. line placed were admitted from the ED. Eight hundred fifty-nine i.v. lines were prehospital placed (27%), and 2,326 were in-hospital placed (73%). There was one infection in the prehospital group and four in the in-hospital group (infection rate: .0012 for prehospital patients and .0017 for in-hospital patients; P = .591 by Fisher's exact test). CONCLUSION: Both cohorts had exceptionally low infection rates. No clinically or statistically significant increase in the risk of infection among prehospital- or in-hospital-initiated i.v. lines was identified.

[croaker260]

WOW, I had thought that practice died out int he early 90's.

JPINV, you might want to provide the complete citiation for his use.

[VentMedic]

This is not a new question and it comes up occasionally in the EDs.

This information pertains to the U.S. Differences in education/training and oversight must be factored in.

First you need to work with your infection control officers and find out the references by which their policies were written from since this is also a CDC recommendation. Medicare and accrediting agencies also like to follow the CDC guidelines.

Then, you need the written policies of every EMS/Ambulance that transports to your facility and their competency sheets. You may be surprised to find some services do not have all their data in order. If all services transporting to your ED can not satisfy general documentation and competency data, you may be hard pressed to change any policies. That has been one of the biggest stumbling block along with EMT(P)s themselves bragging about their "prehospital techniques". Also, what levels of prehospital providers are doing the IVs in your area? How much initial and continuing education do they get on technique and infection control? That also will have to be documented when you present your position. National studies with a limited sampling area may not be enough.

The IHI also has been incorporating various data bases and may be of some help or find out where the weak areas are and you can assist the prehospital agencies in achieving compliance.

I do believe an antecubital IV should be placed in a better location if it is not being used for resuscitation.

Some hospitals have extended their prehospital restart to 48 hours which is just one day shy of the in hosptial policy for site rotation of 72 hours.

WOW, I had thought that practice died out int he early 90's.

JPINV, you might want to provide the complete citiation for his use.

We also change out prehospital ETTs whenever possible if the patient is going to be on a vent for more than 24 hours. We take the infection control issues and the mandates from Medicare very seriously. So far out overall hospital infection rates have decreased dramatically with 0 for VAP and central lines so far. Peripheral IV lines have not been an issue but the hospitals have almost always had the 24 hours change out policy.

You may be the only EMS provider in your area and you may be able to provide the hospital with all the necessary paperwork if ever asked.

However, when one facilty is on the rec'g end of over 15 different EMS/ALS services, many of which have their share of problems, the hospital has gotta do what it must to ensure quality.

Edited April 28, 2009 by VentMedic

[JPINFV]

WOW, I had thought that practice died out int he early 90's.

JPINV, you might want to provide the complete citiation for his use.

Or someone can run the title through Google or Pubmed.

[croaker260]

This is not a new question and it comes up occasionally in the EDs.

This information pertains to the U.S. Differences in education/training and oversight must be factored in.

First you need to work with your infection control officers and find out the references by which their policies were written from since this is also a CDC recommendation. Medicare and accrediting agencies also like to follow the CDC guidelines.

Then, you need the written policies of every EMS/Ambulance that transports to your facility and their competency sheets. You may be surprised to find some services do not have all their data in order. If all services transporting to your ED can not satisfy general documentation and competency data, you may be hard pressed to change any policies. That has been one of the biggest stumbling block along with EMT(P)s themselves bragging about their "prehospital techniques". Also, what levels of prehospital providers are doing the IVs in your area? How much initial and continuing education do they get on technique and infection control? That also will have to be documented when you present your position. National studies with a limited sampling area may not be enough.

The IHI also has been incorporating various data bases and may be of some help or find out where the weak areas are and you can assist the prehospital agencies in achieving compliance.

I do believe an antecubital IV should be placed in a better location if it is not being used for resuscitation.

Some hospitals have extended their prehospital restart to 48 hours which is just one day shy of the in hosptial policy for site rotation of 72 hours.

We also change out prehospital ETTs whenever possible if the patient is going to be on a vent for more than 24 hours. We take the infection control issues and the mandates from Medicare very seriously. So far out overall hospital infection rates have decreased dramatically with 0 for VAP and central lines so far. Peripheral IV lines have not been an issue but the hospitals have almost always had the 24 hours change out policy.

You may be the only EMS provider in your area and you may be able to provide the hospital with all the necessary paperwork if ever asked.

However, when one facilty is on the rec'g end of over 15 different EMS/ALS services, many of which have their share of problems, the hospital has gotta do what it must to ensure quality.

Vent, I think you are misreading my intent. I do not have a problem with the change over of any lines once the patient is admitted , especially if it is reasonable, and prudent and well thought out.

But to rapidly change out the line in the ED, pulling the prehospital line BEFORE future acccess is gained, without regard for the anticipated clinical course of the patient (admitted? Discharge? etc) , "Just because" ...is arogant and just poor medical care, and this is what I saw in the 90s and what I took the OP's situation to be.

[VentMedic]

Vent, I think you are misreading my intent. I do not have a problem with the change over of any lines once the patient is admitted , especially if it is reasonable, and prudent and well thought out.

But to rapidly change out the line in the ED, pulling the prehospital line BEFORE future acccess is gained, without regard for the anticipated clinical course of the patient (admitted? Discharge? etc) , "Just because" ...is arogant and just poor medical care, and this is what I saw in the 90s and what I took the OP's situation to be.

I can see pulling the line immediately if it was infiltrated or otherwise not usable. That would prevent others from wasting time trying to put meds into it.

The issue for the OP is to educate the staff about waiting until a line is in place. If the doctors and nurses are young, they just need a little guidance. We get over eager residents also who sometimes have to be reminded of the P&P or a timeout until they can get themselves oriented to the tasks and their proper order.

Also phlebitis probably won't show up in just 15 minutes after insertion so it is not a valid argument "to not see phlebitis".

EMT(P)s themselves are the ones who have shown their own issues against IVs started in the field. "We're EMS. We don't have time to do it like you do in the hospital."

We've even had issues with Paramedic students in our ED wanting to start IVs like they have been told they would in the field and not by the standards of the hospital. A few students were noted to not even give the site one swipe with alcohol. They were betting with each other who could get the IV in the fastest and cleaning took too long. If this becomes an issue again, the schools may have to look for another ED for IVs. We already have banned intubation by Paramedic students from these schools in our ED. Again, it is hard to maintain quality control for many different schools and many different departments.

Of course, you may not have seen the look on some Paramedics' faces when we do a quick tube change out in the ED.

Edited April 28, 2009 by VentMedic

[ncmedic309]

I've seen numerous lines started in the hospital, in the EDs, on the floors, doing clinical rotations with the IV Team, etc. I can vouch that there is nothing done differently in the hospital that isn't done in the field. I've seen numerous hospital providers start lines, they pop on the tourniquet, palpate the vein, give it one swipe with an alcohol prep and then stick. I've seen some palpate the vein again before the stick and not give it another swipe. I've seen the same in the field with EMS providers.

The problem is, that unless your preparing a sterile surgical field each and everytime you do an IV, your not going to have a "sterile" stick, it's just not possible. It doesn't make a difference if your in the ED, on the floor or in the back of the ambulance. It's my personal opinion, that pulling a good patent line that was initiated only minutes earlier for the achievement of having a "sterile" site is ignorant and a waste of time. You've done nothing but take out a good line and inflict more pain on the patient putting in an additional line and likely increased the risk for possible infection. That's not good medicine...

[celticcare]

Thank you guys for your input *and hope for more from other providers*.

There is only one service in our area and EMT I and upwards do cannulation. I have done the training and spoken to the IV resource people regards auditing within the service and there hasn't been any feedback to them from hospitals about pre hospital leur infections.

The general issue being that people are pulling leurs for the mentality "its a prehospital one and it is dirty" and then not replacing it before hand with an inhospital one or just for the fact of pulling a leur that is patent, flushing, no signs of inflamation or anything for the sake of pulling it because it is a Pre Hospital one.

I have found that article that was posted and again, if anyone has any more information, it would be much much appreciated. We have patients out in the community who are on home IV therapy and when they come into hospital, their leurs arent pulled, yet an ambulance one is. So it just makes me wonder if this is a ward nurse perception of the outside world being so terribly unclean as compared to their hospital environment.

I appreciate mindsets and understanding have a huge part to play and so I just want to see patients go through less pain, less trauma and of course less access of infection if people actually knew the stats, the rates and understaning of the tecnhnique. I have seen plenty of nurses do what was listed here too, swipe with alcohol, palpate the vein and shove it in without another alcohol swab or skin prep swab.

Thanks again team, it is honestly appreciated and look forward to more information and experiences, I have a performance appraisal due next week and want to present some evidence of findings to achieve my level 2 RN certifications. (Which I will buy you guys a beer if I achieve just have to come to expo when I go to one to recieve it *

Scotty

[VentMedic]

So it just makes me wonder if this is a ward nurse perception of the outside world being so terribly unclean as compared to their hospital environment.

Until you've seen a FF/medic try to start an IV with their fire gloves on, you won't understand.