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SGEM#204: Hold the Line – IVs Aren’t Always Required

SGEM#204: Hold the Line – IVs Aren’t Always Required

Podcast Link: SGEM204

Date: January 25th, 2018

Reference: Hawkins et al. Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study. AEM Jan 2018

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency.

Case: You are caring for a patient with a fever in the emergency department and the nurse asks if you want to start an intravenous (IV) line or just draw blood. You think for a minute…your patient is not tachycardic, not vomiting, and the likelihood of discharge is very high.

Background: Emergency department patients often have peripheral IV cannula (PIVC) placed at triage for initial blood draws or “just in case” they are used during the emergency department stay or hospitalization. It is one of the most commonly performed procedures in the emergency department.

PIVC placement can lead to discomfort, infection, and use of time and other emergency department resources (Rickard et al and Stuart et al). Some studies report that up to half of these are never used (Limm et al).


Clinical Question: Can an educational intervention on the appropriate use and placement of PIVCs reduce the number of unnecessary IV placed?


Reference: Hawkins et al. Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study. AEM Jan 2018

  • Population: Emergency department patients greater than17-years-old.
    • Excluded: Triage category 1, PIVC insertion by EMS, or transfers from another hospital
  • Intervention: Ten-week educational training, change champions, advertising, surveillance and feedback
  • Comparison: Pre-intervention data was collected for 12 days before, and 12.5 days after, the intervention. Post-intervention data was collected one month after the intervention.
  • Outcome:
    • Primary Outcomes: Reduction in peripheral IV catheters placed post-intervention and usage
    • Secondary Outcome: PIVC insertion cost (staff and consumables)
Tracey Hawkins

Tracey Hawkins

This is an SGEMHOP episode, so we have the lead author on the show. Tracey Hawkins is a Clinical Nurse and Researcher in the Emergency and Trauma Centre at the Royal Brisbane and Women’s Hospital, Queensland, Australia.  Since 2008, she has been undertaking research into innovative models of cardiovascular care, peripheral intravenous cannulation and emergency care.

Authors’ Conclusions: “The intervention reduced PIVC placement in the ED and increased the percentage of PIVC placed that were used. This program benefits patients and health services alike, with potential for large cost savings.”

checklistQuality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Unsure
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Unsure – It is hard to tell how many staff were trained/exposed (although most likely all staff would see the signs/shirts)
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? Unsure
  7. Was the follow up of subjects complete enough? Yes
  8. How precise are the results? Fairly tight confidence intervals around the point estimate (range 3-5%)
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. Do the results of this study fit with other available evidence? Yes

Key Results:  4,173 patients we included in the study with a median age of 37 with close to a 50/50 male/female split. More than 2/3 of the PIVC were for administration of IV fluids or drugs.


The education intervention decreased the number of PIVC and increased the utilization of those inserted.


  • Primary Outcomes:
    • PIVC Placement: 42.1% Before vs. 32.4% After (difference -9.8%; 95% CI -12.7% to -6.8%) NNT of 10 (This multimodal intervention would prevent 1 PIVC in every 10 patients)
    • PIVC Utilization:
      • Within the Emergency Department: 67.4% Before vs. 79.4% After (difference 12%; 95% CI 8.7% to 17.0%) NNT of 8 (This multimodal intervention would increase utilization of the PIVC in the ED in one in 8 patients)
      • Within 24 Hours of Admission: 70.4% Before vs. 83.4% After (difference 12.9%; 95% CI 8.7% to 17.0%) NNT of 8 (This multimodal intervention would increase utilization of the PIVC within 24hrs of admission in one in 8 patients)
  • Secondary Outcome: It cost less if you did not put in a PIVC. It was quantified as A$4,718 over two weeks (~$3,790 USD or ~$4,689 Can).

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Listen to the podcast on iTunes to hear Tracey’s responses to our nerdy questions.

1) Hawthorne Effect: A challenge with studies using this methodology is the risk of a Hawthorne effect. You used interrupted time-series analysis (or segmented regression analyses) to determine if such an effect was present (Taljaard et al). Can you explain this technique, why it is used and what you found?

2) The Right Number of PIVC: You clearly state there are no accepted guideline on when to place a PIVC in emergency department patients. You used a target of 80% from data coming out of Monash University. The reference for this is a letter to the editor describing a survey that was conducted. The majority of respondents were nurses (58%) and only 24% were emergency physicians. We reached out to the author of the letter to the editor and this survey was not published in a peer reviewed journal. So, we do not know how many PIVC starts are the right number of starts or how much utilization is the right amount of utilization.

Another important detail would be why the PIVC was placed. Having an IV “just in case” in 25 patients who might have hyperkalemia and therefore need urgent management, or who are bradycardic, seems reasonable even if none of them are used. On the other hand, having an IV in place because the cellulitis might be given antibiotics seems avoidable. Do you have the granular details on reasons for PIVC placement?

3) Cost, Time and Failure Rate: You looked at cost savings of PIVC and estimated a savings of about A$2,500/week. With a per-IV staff time of $16, and average insertion time of 15 minutes, that’s $60/hour, which seems high. Can you comment on nurse pay in Australia?

80 percent sure

Are you 80% sure?

You had an intervention that included education and training, change champions, advertising and surveillance and feedback. How much did this cost (including the special shirts) and would it offset any financial gains?

We also wondered about the insertion time of fifteen minutes. This seems like a fairly long time to start an IV and what about the 30% failure on the first attempt? This time is a lot higher than we see. Are experienced nurses placing these IVs, or trainees? We understand that in Australia, cannulas are often done by trainees, whereas they are exclusively done by nurses where we work – did that affect their results?

4) External Validity: This was a single center, tertiary care emergency department in Australia. Different countries have different health care systems with different expectations of patients. Do you think this has external validity to non-tertiary centers and/or emergency departments outside of Australia?

5) Longevity of the Intervention: You measured the outcome one-month after the 10-week intervention. Do you think the 10% improvement you observed will be maintained long term? If not, what would be the cost of an on-going intervention to decrease unnecessary PIVC?

6) Shifting the PIVC to the Ward – You did not measure starting an IV on the ward. Could you have been just shifting the procedure to the in-patient unit?

7) Surrogate Outcome – You did not measure actual harms of PIVC. Are you assuming the 10% net decrease in PIVC would translate into a decrease in clinically important harms?  It appears patients were being poked for blood work anyway. What is the real harm of an IV placed for two hours in the emergency department and then removed?

8) Gestalt – Did you consider measuring clinical gestalt? Perhaps there were some clinicians that were starting IVs all the time and others on the opposite end of the spectrum. It would have been interesting to know the individual clinicians’ ability to predict PIVC utilization. This could identify a potential knowledge gap and could you focus interventions on those individuals rather than everyone?

9) Power Calculation – You powered your study based on an estimated prevalence of 65% based on a local audit. Your actual pre-intervention prevalence was 23% lower at only 42%. Could it have  leaked out you were doing this study and clinicians started fewer PIVC? That would have been a very cost-effective strategy with announcing a study had more than double the impact (23% vs. 10%).

How did the lower prevalence and higher utilization impact your sample size calculation and was the study still adequately powered?

10) Harms – Are there any harms to this intervention? Were there patients who needed an urgent IV medication which was delayed because an IV wasn’t readily available? How many patients had to be poked twice because of the new protocol (once for blood work, and then later for the IV)?

The other side of that is the prior research demonstrating PIVC being used only 50% of the time. However, in your pre-intervention was at 67.4% so you were already doing better by 17%. The intervention only improved by a further 12%. Again, could the more cost-effective strategy simply be announcing you are doing a study soon on the utilization of PIVC?

Is there anything else you would like to tell the SGEMers about your study?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors.


SGEM Bottom Line: Educational interventions can reduce the number of PIVCs placed in the emergency department setting and increased the proportion of PIVCs that are ultimately used but the longevity of such an intervention and the patient oriented benefit is not clear.


Case Resolution: You tell the nurse not to start an IV at this point, as your prediction of it being used is significantly less than 80%. You will reassess later during the patient visit.

Dr. Corey Heitz

Dr. Corey Heitz

Clinical Application: Reducing unnecessary PIVC insertion can potentially increase patient comfort, reduce infections, and reduce costs.

What Do I Tell My Patient? You say that for now, you won’t have an IV started but if the clinical picture changes, your decision may change.

Keener Kontest: Last weeks’ winner was Kyle DeWitt a PharmD from the University of Vermont Medical Center. Kyle knew cortisol is the main glucocorticoid and aldosterone is the main mineralocorticoid.

Listen to the SGEM podcast on iTunes to hear this weeks’ question. If you know the answer send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP AEM

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode? Tweet your comments using #SGEMHOP. What questions do you have for Tracey Hawkins and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:

  • Go to the Wiley Health Learningwebsite
  • Register and create a log in
  • Search for Academic Emergency Medicine – “January”
  • Complete the five questions and submit your answers
  • Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide


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References:

  1. Rickard CM et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet. 2012 Sep 22;380(9847):1066-74. doi: 10.1016/S0140-6736(12)61082-4.
  2. Stuart RL et al. Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services. Med J Aust. 2013 Jun 3;198(10):551-3.
  3. Limm EI, Fang X, Dendle C, Stuart RL, Egerton Warbur- ton D. Half of all peripheral intravenous lines in an Australian tertiary emergency department are unused: pain with no gain? Ann Emerg Med 2013;62:521–5.
  4. Taljaard M, McKenzie JE, Ramsay CR and Grimshaw JM. The use of segmented regression in analysing interrupted time series studies: an example in pre-hospital ambulance care. Implement Sci. 2014 Jun 19;9:77. doi: 10.1186/1748-5908-9-77.