Field-Started vs. Hospital-Started IVs
The risk of complications may be no greater in IVs inserted outside the hospital.
Researchers have reported conflicting results in
trying to determine if peripheral IVs started
“in the field” by emergency services personnel
(EMTs and paramedics) result in a higher incidence
of complications than those started by hospital
staff.
The Centers for Disease Control and Prevention
(CDC) offers extensive guidelines for the use of
any intravascular device, including peripheral IV
lines (
http://www.cdc.gov/ncidod/hip/
iv/iv.htm).1 Based on current research into
intravascular device–related complications such as
phlebitis and infection, these recommendations
are used by health care facilities in writing their
own policies. The CDC advises that all fieldstarted
IVs (sometimes called prehospital IV starts)
be discontinued and new IVs placed after hospitalization.
But the CDC has acknowledged that
there’s no evidence that field-started IVs carry a
greater risk of infection2; furthermore, most
researchers have assumed that such IV starts occur
without aseptic technique. But this assumption is
flawed.
The Intravenous Nursing Standards of Practice
regarding peripheral IV lines give more weight to
what clinicians observe.3 These state that if there
are no signs of complication in the patient or of IV
contamination, the IV shouldn’t be discontinued,
regardless of who started the line and where.
They also state that signs of IV contamination,
phlebitis, or infection warrant immediate discontinuation
of the line.
The latest research supports these recommendations.
One study of peripheral IV–related phlebitis
examined 305 IV sites in 188 adult patients at a
Midwestern hospital.4 There were 10 occurrences
of phlebitis, but none was associated with the five
field-started IVs.
Researchers at a level I trauma center in Ohio
found no compelling data for the mandate that all
field-started IVs be discontinued and restarted at
hospital admission.5 The researchers developed an
algorithm to help nurses decide if a field-started IV
should be discontinued or could be left in place
for up to 72 hours (as IVs started in the hospital
were). Findings of two older studies conflict, yet
neither found high enough complication rates with
field-started IVs to warrant hospital mandates that
would change all such lines on hospitalization.
Lawrence and Lauro found that the risk of complications
increased when IVs were started in the field
by emergency personnel.6 But the study was small
and flawed—one EMT’s use of nonaseptic technique
was deemed responsible for most of the
complications. And a retrospective study by Levine
and colleagues established a lower infection rate
in field-started IVs than in hospital-started IVs.7
Hospitals should allow nurses to assess all IV
lines—both field started and hospital initiated—to
determine whether an IV is compromised. And
nurses should consider the circumstances under
which a line was started. For example, if EMTs
inserted a line while extracting a patient from a
wrecked vehicle, aseptic technique was probably
not used; in such cases, the IV should be discontinued
and restarted. In general, though, in the
absence of contamination or complications, an IV
change—an often painful procedure—isn’t necessary
for all field-started IVs. A more judicious policy
toward field-started IVs will save time and
reduce costs.—Rosalyn Gendreau-Webb, BSN,
RN, an ED staff nurse at Mercy Hospital,
Portland, ME
REFERENCES
1. O’Grady NP, et al. Guidelines for the prevention of intravascular
catheter-related infections. Centers for Disease Control
and Prevention. MMWR Recomm Rep 2002;51(RR-10):1-29.
2. Pearson ML. CDC guideline for prevention of intravascular
device-related infections: Part 1. Intravascular device-related
infections: an overview. Part 2. Recommendations for prevention
of intravascular device-related infections. Infect
Control Hosp Epidemiol 1996;17(7):438-73.
3. Infusion nursing standards of practice. Journal of Intravenous
Nursing 2000;23(6S):S56-S69.
4. White SA. Peripheral intravenous therapy-related phlebitis
rates in an adult population. J Intraven Nurs 2001;24(1):
19-24.
5. Shreve WS, Knotts FB. Quality improvement with prehospital-
placed intravenous catheters in trauma patients. J Emerg
Nurs 1999;25(4):285-9.
6. Lawrence DW, Lauro AJ. Complications from IV therapy:
results from field-started and emergency department-started
IVs compared. Ann Emerg Med 1988;17(4):314-7.
7. Levine R, et al. Comparison of clinically significant infection
rates among prehospital- versus in-hospital-initiated IV lines.
Ann Emerg Med 1995;25(4):502-6.
