Is starting an unnecessary IV fraud?

[Carlos Danger]

And unless you got multi-venous IV training arm at home or at your station there is no way you initiating IV access often enough to maintain adequate proficiency on the poor vasculature patients.

Do you have any evidence to back up that claim?

 

[Tigger]

This is a chief reason intubation is highly contested, we don't do it nearly enough, and very few go to the operating theater for practice. Now before some of you hit your keys with furious anger, I do not advocate intubating everyone you come across. However peripheral IV access does not carry the same deleterious effects when appropriately conducted yet crucial for certain calls.

Perhaps it does not have same deleterious effects when done improperly, but it certainly has a deleterious effect on the patient's wallet in most places. Is that not a concern?

 

[CriticalCareIFT]

I dont insert pharyngeal airways every day, but based on your reasoning, everyone is getting a NPA now.

Patient doesnt NEED an NPA, but i need to practice the skill of measuring a correct size.

First I never stated EVERYONE is getting an IV for practice. I would say the populace that truly requires IV access for medication administration/fluid administration is tiny compared to overall call volume.

Second IV access and Nasal Pharyngeal Airway skills are not at all the same. Have you initiated peripheral IV access on someone in cardiac arrest with non existent vascular tone? Or a diabetic all clenched up on the floor and incontinent? What about heroin user with track marks? Patient with CKD with PICC line in one arm and poor vasculature in the other? Patient that suffered large scale burns and needs IV access for fluids and induction, Dark skin and you are feeling for it? etc. Let see NPA let's measure from patient's nostril to the earlobe and insert.

 

[CriticalCareIFT]

Do you have any evidence to back up that claim?

Certainly it's called empirical evidence. Do you have any evidence to disprove my claim?

 

[medicdan]

I don't buy that starting unnecessary IVs is justified for practice. If you truly believe you need more experience, work to schedule yourself with some ED time to get access on patients who do need it, and are sick, or pick up a side job as an IV tech for nursing homes, or a phlebotomist. The answer is not to perform unnecessary procedures.

 

[chaz90]

Certainly it's called empirical evidence. Do you have any evidence to disprove my claim?

Not the way the scientific process works. Assertions have to be proven with evidence, not disproven.

 

[VFlutter]

I guess none of you saw residents place central lines during cardiac arrest, because certainly main reason they doing it is out of patient necessity.

What is your point? Are implying that residents place central lines during codes because they do not have the skills to place a PIV? Don't worry I am sure the Noctor, I mean RN, will already have a line or two before they even get there.

Also, I have seen some wicked phlebitis and hematomas from IV sticks. Not life threatening but certainly not benign.

 

[CriticalCareIFT]

And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?

 

[Medic Tim]

And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?

Most places no longer allow this.

 

[VFlutter]

And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?

Practicing on a willing participant in an academic setting is totally different than patients. Especially patients who are trusting you as a medical professional to treat them and do not know any better. Also most school no longer allow this practice due to liability.

**Edited for niceness :excl:

 

[ffemt8978]

Play nice or

 

[CriticalCareIFT]

Practicing on a willing participant in an academic setting is totally different than patients. Especially patients who are trusting you as a medical professional to treat them and do not know any better. Also most school no longer allow this practice due to liability.

**Edited for niceness :excl:

Again I am not advocating starting IV access on every single person. However if you only initiate IV access on people you are giving IV medications to that number will be very small to maintain IV skill proficiency.

Let's say we go with "because I might need it later" approach.

Would you object IV access on these patients?

1- Postictal patient, who is now A&OX3 not seizing on your arrival. Family states has hx of epilepsy and had a seizure 20 minutes ago prior to your arrival. If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access?

2- Chest pain 8 (1-10), has cardiac history, 12 lead no elevations or depressions looks normal, sinus rhythm. You protocols do not have IV meds to be given for this call. If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access.


etc...


here is a study utilizing nurses

http://www.ncbi.nlm.nih.gov/pubmed/16157191

"A total of 77% of the IV insertions were successful. Nurses who were older, had more years of experience, were certified in a specialty, and rated themselves higher in insertion skill had significantly more successful insertions than their younger and less-experienced and less-skilled counterparts (P < .001)."

So more experience and more iv sticks = more successful insertions.

 

[Medic Tim]

I think some things are being taken a bit to literally here. I don't think anyone specifically mentioned iv meds as the only time thy would start an iv. Like I said earlier . If I am going to use it I will start one. Every once on a while I will start one on a person I know will get one in te hospital.

Pt 1 would most likely not be transported if that is all that happened. We also use an prefer IM benzos over IV. (Rampart study)

P2 would obviously get an iv as most people would follow an acs protocol ( I med being administered and most likely a bag hung)

 

[Farmer2DO]

I have a low threshold for starting IVs in the field. If:

1.) I know the patient is going to need medication: fentanyl, ondansetron, methylprednisolone. These are no brainers.

2.) Fluids. I also have a low threshold for giving fluids. We carry 500 ml bags. If they're vomiting, they get a bag. If they're going to get an IV bolus, they get a bag. If they meet SIRS criteria, they get a bag.

3.) The potential to give meds. Chest pain, treating for ACS. Seizures that have stopped, but you would treat if they seized again. Stroke symptoms. Those all are good patients to have access in before you need it.

4.) There is a VERY HIGH likelihood the patient will get lined and labbed at the ER. These patient usually meet one of my first three criteria. Our ERs routinely draw off the locks, and the patients are grateful for one stick. The nurses are very grateful that it's been done for them. The patient gets a dispo faster, beds turn over quicker. Everyone wins.

Basically, I am able to justify with sound reasoning every IV I put in. But skill proficiency is not one of them. IMHO, if that's the only reason, it's unethical.

 

[CriticalCareIFT]

Based in the discussion here if you initiated IV access and patient is paying for it, and you are not giving any IV meds or IV fluids that the patient currently requires then IV access that was established is not actually being utilized.

I am very liberal with my 12 lead acquisitions and I have done them on patients whose chief complaint was not chest pain (and at times that abdominal pain turned out to be a STEMI). Should we only be doing 12 lead EKG's on patients with chest pain? Yes the patients are paying for them.

Either way if you employ "because I might need it later" or "maintaining your skills" you have started IV access and have not used it for its intended purpose.

 

[Farmer2DO]

Then you didn't understand my post.

 

[AeroClinician]

I have a low threshold for starting IVs in the field. If:

1.) I know the patient is going to need medication: fentanyl, ondansetron, methylprednisolone. These are no brainers.

2.) Fluids. I also have a low threshold for giving fluids. We carry 500 ml bags. If they're vomiting, they get a bag. If they're going to get an IV bolus, they get a bag. If they meet SIRS criteria, they get a bag.

3.) The potential to give meds. Chest pain, treating for ACS. Seizures that have stopped, but you would treat if they seized again. Stroke symptoms. Those all are good patients to have access in before you need it.

4.) There is a VERY HIGH likelihood the patient will get lined and labbed at the ER. These patient usually meet one of my first three criteria. Our ERs routinely draw off the locks, and the patients are grateful for one stick. The nurses are very grateful that it's been done for them. The patient gets a dispo faster, beds turn over quicker. Everyone wins.

Basically, I am able to justify with sound reasoning every IV I put in. But skill proficiency is not one of them. IMHO, if that's the only reason, it's unethical.

I agree with every bit of this post, and I currently operate this same way.

This is solid reasonable logic, and properly justifies the necessity of pre-hospital venous access.

 

[unleashedfury]

If the pt. is going to / possibly have blood drawn for labs at the hospital during their course of care. How is vascular access prior to arrival, fraud? It's for an actual purpose. Prehospital vascular access allows blood to be drawn faster.

Now I know what some are going to say, " they don't use our line becaus it's a "field line" ". I call BS, I couldn't tell you how many times I see RNs draw blood out of my line upon arrival after aspirating a good 10cc of blood first.

A sizable portion of ALS pt.s have the potential to deteriorate, wouldn't you like to have a line already in place if that happens?

Most hospitals in my area do not draw from at IV site, due to the fact that it may have already had meds and Saline passed through it may "error the results" they will do a Lab draw. and if they are after an ABG its a no brainer that they are going after an artery and not using the established. And yes if the patient does deteriorate its nice to have a patent IV site established for use

I don't buy that starting unnecessary IVs is justified for practice. If you truly believe you need more experience, work to schedule yourself with some ED time to get access on patients who do need it, and are sick, or pick up a side job as an IV tech for nursing homes, or a phlebotomist. The answer is not to perform unnecessary procedures.

Not everyone has this option, around here ER techs are BLS only and IV starts are not part of the protocol for ER techs. Getting ER time is like pulling teeth, even if your medical director is part of the ER. trust me many have tried already to get their profficency up and the hospital gives the long story about why you can't. warranting HIPAA or the Campus policy

And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?

A few students in my class moaned and groaned about this, They wanted to stick everyone else licking their chops. But when it was stick and be stuck the bawled their faces off.

Again I am not advocating starting IV access on every single person. However if you only initiate IV access on people you are giving IV medications to that number will be very small to maintain IV skill proficiency.

Let's say we go with "because I might need it later" approach.

Would you object IV access on these patients?

1- Postictal patient, who is now A&OX3 not seizing on your arrival. Family states has hx of epilepsy and had a seizure 20 minutes ago prior to your arrival. If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access?

2- Chest pain 8 (1-10), has cardiac history, 12 lead no elevations or depressions looks normal, sinus rhythm. You protocols do not have IV meds to be given for this call. If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access.


etc...


here is a study utilizing nurses

http://www.ncbi.nlm.nih.gov/pubmed/16157191

"A total of 77% of the IV insertions were successful. Nurses who were older, had more years of experience, were certified in a specialty, and rated themselves higher in insertion skill had significantly more successful insertions than their younger and less-experienced and less-skilled counterparts (P < .001)."

So more experience and more iv sticks = more successful insertions.

Both patients can warrant IV access. the first since they have a hx of epilepsy, and 1 seizure PTA, establish access and monitor if they have another seizure benzos can go right in that site.

the second. you are giving NTG, and possibly fentanyl or morphine after the 3rd nitro if pain exsists and blood pressure warrants. So your giving your patients Vasodilators, if their pressure takes a dump, You have IV access to compensate.

IMHO I believe its going to come down to Local protocol, paramedic experience and general impression of the patient. I know the ED around here gets themselves in a tuff if the patient comes in ALS with no IV access, not even an attempt. The big thing that's pushed as an ALS provider is everyone gets IV O2 and Cardiac monitor. which in a perfect world that's great. Yet its not required. So when you have a borderline call whether or not you want to start IV access, some do just as a safety net.

comes down to symptoms and complaints. If the patient you are treating complains of nausea vomiting x 2 days. limited PO inputs. hanging an IV bag to combat dehydration maybe push some Zofran if its warranted.

your respiratory distress patient. give a duo neb. Start an IV maybe some solu Medrol if the the patient can benefit from it. Granite takes 4-6 hours to work but your ahead of the game.

In Pa I'm not too sure about other states ALS is an all inclusive rate, you pay a flat fee of ALS rate, or BLS rate, plus mileage billed in tenths of a mile. so if your mileage rate is 10.00/mile you take the patient 10.3 miles they pay 103.00 for transport mileage.


to the poster who stated that ECG monitors are going to become a BLS thing is hogwash. In a round about way if you have Cardiac monitoring a BLS skill, Yes BLS can obtain a strip. but who will interpret it. Pass it along to the ED via Wireless transfer for interpretation Ok fine. now you have to tie up a doc to read ECG strips amongst other duties he will have to perform as a physician. If your stating that EMT basics will learn to interpret ECG's how will they treat any abnormalities? It will also drive the cost of BLS services up since you are now adding another skill that a BLS provider can perform.

IV access vs no IV access to start a line on somebody because you "need to practice the skill" is unethical, However if based on your experience and you look at your patient and say well he/she could probably benefit from IV access for some Fluids or cause I might just end up giving so and so med. its justifiable, In the end it will be up to the QA manager to read your reports and see if your patient required access. and if so did you justify why?

 

[medicsb]

It IS reasonable to start IVs if you suspect there will be a need for it (e.g. ACS, respiratory failure, etc.) due to patient deterioration. However, you should not be apply "what if's" to everyone who gets on your ambulance. We already know that most patient do not require IV meds during transport, and many never require any during their ED stay. I reject the "they'll get one in the ED anyways" argument. Let them get the IV in the ED if the RN or doc want it, but that should not be used to justify your IV (especially when many hospitals mandate removal of prehospital IVs within 24 hours).

With the prevalence of IOs, the argument over the need for experience with difficult IV sticks is almost moot. Also, if most EMS systems were truly tiered, there'd be little discussion because the patients that paramedics would transport would actually be ALS patients. But, yeah, when you're sent to every call and you (or your medical director and/or other stake-holders) need to justify your existence despite the fact that 80% of your patients only need a ride, of course you'll start resorting to "what if" scenarios to justify treatment.

 

[unleashedfury]

It IS reasonable to start IVs if you suspect there will be a need for it (e.g. ACS, respiratory failure, etc.) due to patient deterioration. However, you should not be apply "what if's" to everyone who gets on your ambulance. We already know that most patient do not require IV meds during transport, and many never require any during their ED stay. I reject the "they'll get one in the ED anyways" argument. Let them get the IV in the ED if the RN or doc want it, but that should not be used to justify your IV (especially when many hospitals mandate removal of prehospital IVs within 24 hours).

With the prevalence of IOs, the argument over the need for experience with difficult IV sticks is almost moot. Also, if most EMS systems were truly tiered, there'd be little discussion because the patients that paramedics would transport would actually be ALS patients. But, yeah, when you're sent to every call and you (or your medical director and/or other stake-holders) need to justify your existence despite the fact that 80% of your patients only need a ride, of course you'll start resorting to "what if" scenarios to justify treatment.

Well I can agree to that not everyone needs an IV, and the what if's can be narrowed down by a good assessment, Some BLS patients may benefit from ALS interventions, like your nausea vomiting patient is technically BLS but can benefit if administered Zofran, IIRC we are not required to carry the tablets, so IV is your route.

In my area IO's are primarly a last resort in adults. mostly used in cardiac arrests especially your morbidly obese patients where IV access is limited.