What IS the rate of field IV infections?

[medicdan]

I know several hospitals in the areas where I work, that unless they need it immediately, will pull field (Intermediate or Paramedic acquired) IVs for fear of infection. This brings up a few questions for me (I use "us" and "our" terms to specify EMS (ILS and ALS personnel), not necessarily myself):

1) What really is the rate of infections (phlebitis, etc) for field lines compared to hospital lines? Are there any studies that I have missed on my pubmed search?
2) What makes our aseptic technique so different from theirs?
3) Is an infection from one of our lines considered a "never" event for hospitals (CMS won’t pay...?) How is it determined that it was our fault? Is there a threat to our billing for an infection?
4) What effect do these standards have on the number of patients accessed in the field (the ILS service I worked with gave a lot of patients’ lives TKO "Just in case the hospital needs them")? What effect does these staff performing fewer procedures have on the times when a patient really needs a line?
5) What effect does this assumption of contamination have on pre-hospital blood draws, by said agencies, which, after they draw the blood, just leave the line in TKO?

Is this moving the way we see endotracheal intubations going-- services moving towards mandating Kings or LMAs for arrests because field tubes are pulled and replaced anyway? Services allowing for CPAP instead of intubations for CHF/COPDers?

Again, I really am not posing this as an ALS v BLS question. It also isn’t "Should these procedures still be performed in the field", but more of "is all of this in the BEST long-term interest of the patient"?

Thanks to all who reply constructively.


Dan

 

[HotelCo]

2) What makes our aseptic technique so different from theirs?
...
Is this moving the way we see endotracheal intubations going-- services moving towards mandating Kings or LMAs for arrests because field tubes are pulled and replaced anyway?

Thanks to all who reply constructively.


Dan

Not much, but I do agree with the hospital doing one other line to use as their primary. We don't always have the cleanest of conditions when doing an IV (dirt blowing all around and what not). But, I do fail to see why they can't use our IV as their second line, instead of putting in another after their first one.


(Not a seasoned EMS provider here but...) I've never seen a field tube that was placed properly pulled and replaced. I don't understand why anyone would do that anyway. Perhaps the tubes that you saw were not placed properly? I do like having the ET option, however I think that LMAs or Kings are great to use, very simple, and waste less time than fiddling with intubation.

 

[alphatrauma]

2) What makes our aseptic technique so different from theirs?

Dan

Having spent the majority of my career "in hospital", I can tell you that even in a controlled environment (ER, ICU, etc...), IV starts are hardly "aseptic". As the setting becomes more dynamic, so does the increased propensity for poor technique ( ie: contamination).

A few things that I have actually witnessed (and are commonplace):


- crisscross a strip of tape over the insertion site... the same strip of tape that was just stuck on the siderail or bedside table.

- occluding the vein right on the insertion site

- picking supplies off the floor and still using them

- placing anything underneath the biocclusive dressing


In my opinion, field IV starts are just plain dirty (yes, including my own)

 

[Veneficus]

The issue is now cost.

Medicare stopped paying for care for condtions that could have been "prevented." Which means if you start a line, pt gets phlebitis, the hospital now eats the costs for that. No different than if the hospital starts the line they eat the cost.

That has forced facilities to upgrade their efforts for prevention. But best practice should not cause people to not initiate IV therapy in the field when it is needed. The hospital pulling and starting another line is not the end of the world. A lot of field providers see this as an insult to their ability. Really it isn't.

IV therapy is invasive, and because it is done very frequently, the risks and side effects are perhps overlooked. These new rules just mean providers will have to use more discretion. Gone are the days of starting IVs on every patient so you can bill ALS or "just in case." Some exposure to what happens to the patient from the time they get to the hospital to discharge would help a lot in field providers making better decisions. I don't forsee agencies paying for it, so individuals may have to take that initiative on their own, but it really will help you provide better care for patients.

Field providers are also not the only ones who don't understand that. My anesthesia preceptor argued with a nurse a couple weeks ago because the nurse said it was easier to leave a post op patient on a vent then it is to try and wake them up monitor them and send them to the ICU w/o a vent. It is better for the patient though.

Many field providers also do not know that IV lines are even replaced in the hospital. An IO is not a sterile procedure in the ED, but it is in the ICU, so they will be pulled and replaced. In the ICU and even the regular wards IV lines started in the ED are replaced when the patient gets to the floor. Once there the lines are routinely replaced roughly every 24 hours.

 

[bstone]

Man, if IV inserts are cause for phebilits then I had to think about IOs. What about bilateral IOs?

 

[MasterIntubator]

The contamination factor in hospitals is quite staggering. More so than our band-aid buggies. Probably because most of spend a great deal more time cleaning a small area. You figure, many coming out of hospitals end up catching some sort of secondary pneumonia or bacterial infection.

The last report I read, is that field IVs were just about as good as most hospital IVs. There were exceptions, especially the facilities that actually do a full scrub for thier IV insertion. Our rate of phlebitis was not much higher.

I would ( and do ) take a little more time and care when it comes to diabetics and immune supressed folks.

If I find that link of the report RE: nosocomial infections between field and hospital based providers.

 

[Melbourne MICA]

Pulling IV's

Pulling EMS IV lines by the hospital on arrival at ED doesn't seem to make sense to me. From an infection standpoint, all IV sites are recolonised within 24-72hrs. Pulling the EMS line and placing another just creates another portal of entry for a localised infection that is inevitable anyway. ICU'S routinely replace their own IV's within fixed time frames and treat with AB"S.

On aseptic technique - this is not possible in the field for practical and environmental reasons. Even if you used a mask and sterile gloves and say were on the street, wind will blow dust compromising your measures. We do our best to keep IV sites clean - this is all that can be expected under the circumstances.

I'm shocked to hear any ALS procedure would be carried out in order to procure a billing cost to a third party like a hospital.

Veneficus I couldn't agree more with your comment about the clincial necessity and responsibility to start lines in the filed when required irrespective of hospital practice. Besides I woud love hospitals or medicare to prove our practcies were a cause of a specific infection - even in ICU's there is recognised level of inevitable infections in pts and the last I time I read a study about the issue they lose about 5-7% of pts to infection anyhow.

Having said all this good preventative clincial measures remain as important as they ever were including how much attention we pay to aseptic technique.

The bugs are winning after all.

MM

 

[Veneficus]

Pulling EMS IV lines by the hospital on arrival at ED doesn't seem to make sense to me. From an infection standpoint, all IV sites are recolonised within 24-72hrs. Pulling the EMS line and placing another just creates another portal of entry for a localised infection that is inevitable anyway. ICU'S routinely replace their own IV's within fixed time frames and treat with AB"S.

I don't think it makes sense either, but in the US the fact is the hospital has no say or control over field procedures. The thinking is that since it will be the hospital, not the EMS provider, that gets stuck with caring for the patient without compensation, they can put procedures and practices in place to reduce infections.

If you really wanted to see US EMS get a kick to be better have joint commison over see them too.

On aseptic technique - this is not possible in the field for practical and environmental reasons. Even if you used a mask and sterile gloves and say were on the street, wind will blow dust compromising your measures. We do our best to keep IV sites clean - this is all that can be expected under the circumstances.

The same in the ED, but only so much can be done. I still don't think the idea of pulling field lines is actually going to do anything to reduce infection, but I am not an infectious disease expert and will have to defer to their judgement.

I'm shocked to hear any ALS procedure would be carried out in order to procure a billing cost to a third party like a hospital.

A sad fact of life in the US. Safetynets like medicare/medicade pay for procedures, not knowledge. It is why there is a shortage of primary care and why our healthcare system spends so much without meaningful results. But here are some facts:

You can get almost double if you are in EMS and put a patient on a monitor and start a line.

At least one level I trauma center I know of doesn't do abd. CTs, but instead does exploratory laparotomy. The logic is that it is paid in full at more than 100x the reimbursement of a CT. (think of the potential complications for the patient of that)

It is common practice for EMS agencies to increase treatment to "ALS" levels "just in case" or directly encouraged by management. Very cleaverly packaged as "be a patient advocate, use everything you have for the benefit of the pt." As it would be illegal to suggest purposefully increasing procedures for better renumeration.

Veneficus I couldn't agree more with your comment about the clincial necessity and responsibility to start lines in the filed when required irrespective of hospital practice..

Sadly some will use this as an opportunity to do less.

Besides I woud love hospitals or medicare to prove our practcies were a cause of a specific infection - even in ICU's there is recognised level of inevitable infections in pts and the last I time I read a study about the issue they lose about 5-7% of pts to infection anyhow.

The beauty is they don't have to prove it. They are not paying for it. Seems like a good way to knock off payments to reduce spending without "compromising patient care". Everyone knows there will still be complications. It is not the relatively healthy young patients this will effect, it will be the cost for immunocompromised, elderly, and others that require high levels of treatment after such "preventable" occurances.

Having said all this good preventative clincial measures remain as important as they ever were including how much attention we pay to aseptic technique.

The bugs are winning after all.

MM

I agree with the first part here, but I doubt it will have any measurable effect on prehospital providers who claim "medicine is different in the field" as if scientific principle takes a leave outside the hospital door.

I don't see it as me vs bugs, i see it as having to deal with the fallout from past providers that killed all the weak ones that were keeping the really nasty
ones in check.

 

[VentMedic]

EMS has been its own worst enemy by bragging "the way we do it in the field" which has gotten hospitals a little cautious. We have even had problems getting Paramedic students to conform to a good cleaning technique during their ED rotations because they have "been taught the EMS way" which means as fast as possible because "it is always an emergency". You also can not imagine what it is like to watch someone attempt to start an IV or intubate with their FF gloves on.

The main issue been has been, when asked, many of the ambulance services and FDs can not come up with a statement of training or documentation of competency.

Since it has been policy for restarting IVs for the past 25 years in most hospitals it is difficult to know how prehospital IVs would do for infections. However, since many EMS IVs are started in the antecubitals, it makes sense for patient mobility and comfort to restart in a more appropriate location.

Of course, you should see the Paramedic's face in the ED when we pull the ETT to place one of the hospital's to prevent VAP if the patient will be on a ventilator for more than 24 hours. Nasal ETTs barely make it to the other stretcher before we are ready to get the tube changed.

We do, however, wait until a good line and the patient is somewhat stable. So far we haven't had a peripheral IV infection or VAP in over 3 years by establishing our own lines and tubes in the hospital which is impressive for a fairly large facility.

 

[BruceD]

Found a couple of references:
Robert Levine, Daniel W Spaite, Terence D Valenzuela, Elizabeth A Criss, A.Lawrence Wright, Harvey W Meislin, Comparison of Clinically Significant Infection Rates Among Prehospital- Versus In-Hospital-Initiated IV Lines, Annals of Emergency Medicine, Volume 25, Issue 4, April 1995, Pages 502-506

Briefly stated:
Was a study of IV line site infections among patients admitted to ward beds from a university hospital emergency department in 1992. 3185 patients, 859 IVs were prehospital. Infection rates of .0012 (pre-hospital) and .0017 for in-hospital.

and a newer study:
Spaite DW, Valenzuela TD, Criss EA, Meislin HW, Hinsberg P.,
Peripheral intravenous catheters started in prehospital and emergency department settings. Journal of the Society of Trauma Nurses, 2008 Apr-Jun;15(2):47-52.

Just gonna quote it, I'm gettin lazy 'n tired.

The purpose of this study was to determine the rates of phlebitis in trauma patients according to where the peripheral intravenous catheter (PIVC) was inserted in a prehospital setting or in an emergency department setting. Variables investigated also included where the catheter was anatomically placed, the gauge of the catheter, and the patients' Injury Severity Score. The overall phlebitis rate was 5.79%. The rate of phlebitis was 2.92% when started by an RN in the emergency department, 6.09% when started by an intermediate emergency medical technician and 7.78% when started by a paramedic in prehospital setting. There was no significant difference in the rates of phlebitis when a chi-square analysis was performed. In addition, no variables predicted phlebitis no matter where the PIVC was started when a regression analysis was conducted. Even though the Centers for Disease Control and Prevention suggests removing the PIVC within 48 hours if placed under emergency situations, the phlebitis rates of trauma patients in this study meet the benchmark of best practice. Perhaps removing the PIVC within 48 hours of placement should be reconsidered.

Hope that helps a little, even though the results seem ... well, anyway.

stay safe.
-B

 

[VentMedic]

and a newer study:
Spaite DW, Valenzuela TD, Criss EA, Meislin HW, Hinsberg P.,
Peripheral intravenous catheters started in prehospital and emergency department settings. Journal of the Society of Trauma Nurses, 2008 Apr-Jun;15(2):47-52.

I don't have any nurse pals nearby right now to pull up this article but it appears to be a faculty submission from Brigham Young University. I honestly have no idea about the EMS situation in Utah. Often doctorate level college faculty submissions are written because they are required.

This study also included IVs started in the ED. That is different from other studies which looked at primarily prehospital starts. Our hospital and many others usually want the ED RNs to restart the IV before the patient gets to the unit or floor.

Like many of the other EMS "skills", it will depend on medical oversight for competency, how busy the service is and whether they utilize their skills frequently or just provide a ride to the hospital under the name of "ALS". We have already seen the controversy with the ETI and there are some services that start IVs about as often as they intubate which might be very few times per year. Also, hospitals must consider the many different services that bring patients to their ED. If there is only one EMS agency in town, it might be easier to see their technique and have some control over quality.

 

[BruceD]

Heh, ya, wasn't sure about that study.
I couldn't pull up the full text either, but it seemed... odd

Thanks Vent.
-B

 

[Jon]

Vent - Do you folks use one of the anti-VAP ET tube systems, with the low-flow constant suction? I saw those for the first time in the ICU a month or two ago - Our facility has no VAP cases for over a year after switching to them. Amazing!

Our ER is very flexible with field IV's. The one paramedic unit is hospital-based, and their IV's are often treated the same as an in-hospital one. That medic unit draws blood when possible for the ED as well, so as to minimize the number of sticks needed per patient. Of course, the floors hate ED IV access... so thats usually where it all gets switched over to a pretty IV started by the IV Team RN's in the perfect world of the inpatient unit of the hospital.

Further, I see a VERY common trend in the ED's these days - if the Pt. needs lab work, we stick an IV in.... doesn't take any longer. Many of these IV's are pulled in 2-4 hours, and if anything, the Pt. might have gotten a liter of fluid.

 

[Melbourne MICA]

Take a deep breath MM

I don't think it makes sense either, but in the US the fact is the hospital has no say or control over field procedures. The thinking is that since it will be the hospital, not the EMS provider, that gets stuck with caring for the patient without compensation, they can put procedures and practices in place to reduce infections.

If you really wanted to see US EMS get a kick to be better have joint commison over see them too.




The same in the ED, but only so much can be done. I still don't think the idea of pulling field lines is actually going to do anything to reduce infection, but I am not an infectious disease expert and will have to defer to their judgement.



A sad fact of life in the US. Safetynets like medicare/medicade pay for procedures, not knowledge. It is why there is a shortage of primary care and why our healthcare system spends so much without meaningful results. But here are some facts:

You can get almost double if you are in EMS and put a patient on a monitor and start a line.

At least one level I trauma center I know of doesn't do abd. CTs, but instead does exploratory laparotomy. The logic is that it is paid in full at more than 100x the reimbursement of a CT. (think of the potential complications for the patient of that)

It is common practice for EMS agencies to increase treatment to "ALS" levels "just in case" or directly encouraged by management. Very cleaverly packaged as "be a patient advocate, use everything you have for the benefit of the pt." As it would be illegal to suggest purposefully increasing procedures for better renumeration.



Sadly some will use this as an opportunity to do less.



The beauty is they don't have to prove it. They are not paying for it. Seems like a good way to knock off payments to reduce spending without "compromising patient care". Everyone knows there will still be complications. It is not the relatively healthy young patients this will effect, it will be the cost for immunocompromised, elderly, and others that require high levels of treatment after such "preventable" occurances.



I agree with the first part here, but I doubt it will have any measurable effect on prehospital providers who claim "medicine is different in the field" as if scientific principle takes a leave outside the hospital door.

I don't see it as me vs bugs, i see it as having to deal with the fallout from past providers that killed all the weak ones that were keeping the really nasty
ones in check.

Venny you've taken my breath away with some of these revelations. Whilst I don't think I'm naeve about moneys impact on the health system - the games the hospitals and specialists play here for dollars in their pockets is comparable - I'm still gobsmacked by some of the collusions to manipulate the flow of the money stream. We idealistic altrusitic fools need to punch ourselves in the moosh from time to time so we can wake up and smell the stuff that's being shovelled.

On the bugs issue - I read one report, I think from the CDC or maybe in abook which estimated the complete collapse of antibiotic Rx regimes for infections within approximately 50 yrs - the bugs are winning.

Now what dufus took the AB's like a big woose when he should have just hardened the F*** up and taken the pain and suffering for all our sakes!!!!

Oh that's right - there are millions of dufuses all over the world.

MM

 

[VentMedic]

Vent - Do you folks use one of the anti-VAP ET tube systems, with the low-flow constant suction? I saw those for the first time in the ICU a month or two ago - Our facility has no VAP cases for over a year after switching to them. Amazing!

Our ER is very flexible with field IV's. The one paramedic unit is hospital-based, and their IV's are often treated the same as an in-hospital one. That medic unit draws blood when possible for the ED as well, so as to minimize the number of sticks needed per patient. Of course, the floors hate ED IV access... so thats usually where it all gets switched over to a pretty IV started by the IV Team RN's in the perfect world of the inpatient unit of the hospital.

Further, I see a VERY common trend in the ED's these days - if the Pt. needs lab work, we stick an IV in.... doesn't take any longer. Many of these IV's are pulled in 2-4 hours, and if anything, the Pt. might have gotten a liter of fluid.

Yes, we use the subglottic tubes and are now in the trial phase of the silver coated tubes. I know silver worked great for the trach many years ago even though they were a pain to clean. Before disposable equipment, out ventilators also had a copper mesh in the humidification pot.

Subglottic suction system
http://www.zapvap.com/_pdfs/inservice_poster.pdf

BARD is the manufacturer of the silver tubes which are easily recognized by the purple connector.
http://www.medgadget.com/archives/2008/08/silver_coating_fights_ventilator_related_pneumonia.html

Both tubes are very expensive and probably won't make it into the prehospital world.

Our RNs are monitored for quality in the ED for their IVs as are the doctors and whoever needs central line experience. We also draw labs from new lines and for kids, I'll butterfly if blood is needed from an arterial stick. If the patient is going to be on a ventilator for more than 24 hours or is in need of BP monitoring, we'll just slip and A-line in which are also closely monitored but have come back clean. For studies, we send the catheter after decannulation to see if there was any growth. It is difficult sometimes to judge phlebitis and infection for lines by just appearance and our policy for change out is very strict. Thus, another reason some studies are skewed in their methodology.

Even our inhouse intubation technique is critiqued constantly. We just can not afford to have an insurance refuse coverage due of an infection. Any VAP goes back to the RT department even though it is part of a whole protocol bundle involving others also. Of course that strict oversight of quality and good technique carries over to the Flight, CCT and Specialty teams and it becomes second nature. So, it doesn't take any longer to do good technique as it does a bad one even in cramped or dirty spaces.