Effects of the MAGIC Guidelines on PICC Placement Volume: Advanced Practice Provider and Physician Trends Among Medicare Beneficiaries From 2010 to 2018.

BACKGROUND. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was published in 2015, recommending more restricted indications for peripherally inserted central catheter (PICC) placement, particularly for those placed by physicians. Changes in PICC placement volume since the publication of MAGIC is largely unknown. OBJECTIVE. The purpose of this article was to study the trends in volume and reimbursement for PICC placement by physicians and advanced practice providers (APPs) for Medicare enrollees from 2010 to 2018 with specific attention to the changes in volume after the publication of MAGIC in 2015. METHODS. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010-2018 were extracted using the Current Procedural Terminology code for PICC placement. Total volume and payment amounts (for the professional component) were analyzed. Trendline slopes for volume per 100,000 Medicare beneficiaries before and after the 2015 publication of MAGIC were compared. RESULTS. Volume for PICC placement by physicians and APPs steadily declined from 243,837 in 2010 to 130,361 in 2018 (46.5%). The PICC placement volume decreased sharply after the 2015 publication of the MAGIC guidelines. The slope of the trendline for all providers from 2010 to 2015 was -3.4 compared with -7.3 from 2015 to 2018. The change in slope was more pronounced for radiologists (-3.1 to -5.6) than for APPs (0.0 to -1.1). Professional payment per procedure for radiologists decreased from $78.04 in 2010 to $70.17 in 2018, and reimbursement for APPs proportionally decreased from $65.76 to $60.66 during this time. The relative share of PICC placement by radiologists declined from 77.0% in 2010 to 70.6% in 2018, with a corresponding increase in relative share by APPs from 13.5% to 18.4%. The percentage placed in outpatient procedures increased from 15.1% to 18.2%. CONCLUSION. The volume of PICC placements has steadily decreased since 2010, with a sharper decline between 2015 and 2016 corresponding with the publication of the MAGIC evidence-based guidelines. The role of APPs in PICC placement has increased over this time period. CLINICAL IMPACT. The findings of this study suggest that evidence-based guidelines impact clinical practice on a national level.

Peripheral venous access using devices over needles with and without extension: costs and outcomes.

OBJECTIVES: to analyze the mean direct cost and peripheral venous access length outcomes using devices over needle with and without extension. METHODS: quantitative, exploratory-descriptive research. Venous punctures and length of the devices were followed. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals by the unit cost of labor, adding to the cost of materials. RESULTS: the total mean direct cost of using devices "with extension" (US$ 9.37) was 2.9 times the cost of using devices "without extension" (US$ 4.50), US$ 7.71 and US$ 2.66, respectively. Totaling 96 hours of stay, the "device over needle with extension" showed a lower occurrence of accidental loss. CONCLUSIONS: the use of the "device over needle with extension", despite its higher mean direct cost, was more effective in favoring adequate length of peripheral venous access.

Cost analysis comparison between peripherally inserted central catheters and implanted chest ports in patients with cancer-A health economic evaluation of the PICCPORT trial.

BACKGROUND: A reliable central venous access device is a cornerstone in the treatment of cancer. Both peripherally inserted central catheters (PICC) and totally implanted chest ports (PORT) are commonly used for the delivery of chemotherapy. Both types of catheter can cause adverse events such as catheter-related deep venous thrombosis (CR-DVT), infection and mechanical complications. METHOD: We conducted a randomized controlled trial including 399 patients with cancer and performed a health economic evaluation investigating the cost related to PICCs and PORTs using several clinically relevant dimensions from a healthcare perspective. The cost was determined using process and cost estimate models. RESULT: PICCs are associated with a higher total cost when compared with PORTs. Combining the costs of all categories, the prize per inserted device was 824.58 EUR for PICC and 662.34 EUR for PORT. When adjusting for total catheter dwell time the price was 6.58 EUR/day for PICC and 3.01 EUR/day for PORT. The difference in CR-DVT was the main contributor to the difference in cost. The daily cost of PICC is approximately twice to that of PORT. CONCLUSION: We have demonstrated that the cost from a healthcare perspective is higher in cancer patients receiving a PICC than to those with a PORT. The difference is driven mainly by the cost related to the management of adverse events. Our findings are relevant to anaesthetists, oncologists and vascular access clinicians and should be considered when choosing vascular access device prior to chemotherapy.

Peripheral venous access using devices over needles with and without extension: costs and outcomes / Acceso venoso periférico utilizando dispositivos de aguja con y sin extensión: costos y resultados / Acesso venoso periférico utilizando dispositivos sobre agulha com e sem extensão: custos e desfechos

ABSTRACT Objectives: to analyze the mean direct cost and peripheral venous access length outcomes using devices over needle with and without extension. Methods: quantitative, exploratory-descriptive research. Venous punctures and length of the devices were followed. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals by the unit cost of labor, adding to the cost of materials. Results: the total mean direct cost of using devices "with extension" (US$ 9.37) was 2.9 times the cost of using devices "without extension" (US$ 4.50), US$ 7.71 and US$ 2.66, respectively. Totaling 96 hours of stay, the "device over needle with extension" showed a lower occurrence of accidental loss. Conclusions: the use of the "device over needle with extension", despite its higher mean direct cost, was more effective in favoring adequate length of peripheral venous access.

RESUMEN Objetivos: analizar el costo directo promedio y los resultados de permanencia del acceso venoso periférico, utilizando dispositivos de aguja con y sin extensión. Métodos: investigación cuantitativa, exploratoria descriptiva. Se siguieron los pinchazos venosos y el tiempo de permanencia de los dispositivos. El costo directo promedio se calculó multiplicando el tiempo (cronometrado) dedicado por los profesionales de enfermería por el costo unitario de la mano de obra, lo que se suma al costo de los materiales. Resultados: el costo directo promedio total de usar dispositivos "extendidos" (US$ 9,37) fue 2,9 veces el costo de usar dispositivos "no extendidos" (US$ 4,50) de materiales, US$ 7.71 y US$ 2.66, respectivamente. Con un total de 96 horas de estadía, el "dispositivo de aguja extendida" mostró una menor ocurrencia de pérdida accidental. Conclusiones: a pesar del costo directo promedio más alto, el uso de un "dispositivo de aguja extendida" fue más efectivo para favorecer un tiempo de acceso venoso periférico adecuado.

RESUMO Objetivos: analisar o custo direto médio e os desfechos de permanência de acesso venoso periférico, utilizando dispositivos sobre agulha com e sem extensão. Métodos: pesquisa quantitativa, exploratório-descritiva. Acompanharam-se as punções venosas e o tempo de permanência dos dispositivos. Calculou-se o custo direto médio multiplicando-se o tempo (cronometrado) despendido por profissionais de enfermagem pelo custo unitário da mão de obra, somando-se ao custo dos materiais. Resultados: o custo direto médio total do uso de dispositivo "com extensão" (US$ 9,37) foi 2,9 vezes do que o custo do uso de dispositivo "sem extensão" (US$ 4,50), destacando-se os custos dos materiais, US$ 7,71 e US$ 2,66, respectivamente. Totalizando 96 horas de permanência, o "dispositivo sobre agulha com extensão" apresentou menor ocorrência de perda acidental. Conclusões: o uso do "dispositivo sobre agulha com extensão", apesar do maior custo direto médio, foi mais eficaz para favorecer o adequado tempo de permanência do acesso venoso periférico.

Direct cost of peripheral catheterization by nurses.

OBJECTIVE: To measure the average direct cost of peripherally inserted central catheterization performed by nurses in a pediatric and neonatal intensive care unit. METHOD: A quantitative, exploratory-descriptive, single-case study, whose sample consisted of the non-participant observation of 101 peripherally inserted central catheter procedures. The cost was calculated by multiplying the execution time (timed using a chronometer) spent by nursing professionals, participants in the procedure, by the unit cost of direct labor, added to the cost of materials, drugs, and solutions. RESULTS: The average direct cost of the procedure was US$ 326.95 (standard deviation = US$ 84.47), ranging from US$ 99.03 to US$ 530.71, with a median of US$ 326.17. It was impacted by material costs and the direct labor of the nurses. CONCLUSION: The measurement of the average direct cost of the peripherally inserted central catheter procedure shed light on the financials of consumed resources, indicating possibilities of intervention aiming to increase efficiency in allocating these resources.

Direct cost of peripheral catheterization by nurses / Costo directo del paso de catéter central de inserción periférica por enfermeros / Custo direto da passagem de cateter central de inserção periférica por enfermeiros

ABSTRACT Objective: To measure the average direct cost of peripherally inserted central catheterization performed by nurses in a pediatric and neonatal intensive care unit. Method: A quantitative, exploratory-descriptive, single-case study, whose sample consisted of the non-participant observation of 101 peripherally inserted central catheter procedures. The cost was calculated by multiplying the execution time (timed using a chronometer) spent by nursing professionals, participants in the procedure, by the unit cost of direct labor, added to the cost of materials, drugs, and solutions. Results: The average direct cost of the procedure was US$ 326.95 (standard deviation = US$ 84.47), ranging from US$ 99.03 to US$ 530.71, with a median of US$ 326.17. It was impacted by material costs and the direct labor of the nurses. Conclusion: The measurement of the average direct cost of the peripherally inserted central catheter procedure shed light on the financials of consumed resources, indicating possibilities of intervention aiming to increase efficiency in allocating these resources.

RESUMEN Objetivo: Medir el costo directo promedio del paso de catéter central de inserción periférica por enfermeras en una unidad de cuidados intensivos pediátrica y neonatal. Método: Investigación cuantitativa, exploratoria-descriptiva, del tipo estudio de caso único, cuya muestra se constituyó de la observación no participante de 101 pasos de catéter central de inserción periférica. El costo se calculó multiplicando el tiempo (cronometrado) de los profesionales de enfermería, participantes en el procedimiento, por el costo unitario de mano de obra directa, sumándose al costo de materiales/medicamentos/soluciones. Resultados: El costo directo medio del procedimiento correspondió a US$ 326,95 (desviación estándar = US$ 84,47), variando entre US$ 99,03 y US$ 530,71, con mediana de US$ 326,17, habiendo sido impactados por los costos con material y mano de obra directa de los enfermeros ejecutantes. Conclusión: La medición del costo directo medio del paso del catéter central de inserción periférica confirió visibilidad financiera a los insumos consumidos, indicando posibilidades de intervención pretendiendo incrementar su eficiencia alocativa.

RESUMO Objetivo: Mensurar o custo direto médio da passagem de cateter central de inserção periférica, por enfermeiros, em uma unidade de terapia intensiva pediátrica e neonatal. Método: Pesquisa quantitativa, exploratório-descritiva, do tipo estudo de caso único, cuja amostra se constituiu da observação não participante de 101 passagens de cateter central de inserção periférica. O custo foi calculado multiplicando-se o tempo (cronometrado) despendido por profissionais de enfermagem, participantes do procedimento, pelo custo unitário da mão de obra direta, somando-se ao custo dos materiais/medicamentos/soluções. Resultados: O custo direto médio do procedimento correspondeu a US$326.95 (desvio-padrão = US$ 84.47), variando entre US$99.03 e US$530.71, com mediana de US$326.17; tendo sido impactado pelos custos com material e mão de obra direta dos enfermeiros executantes. Conclusão: A mensuração do custo direto médio da passagem de cateter central de inserção periférica conferiu visibilidade financeira aos insumos consumidos, indicando possibilidades de intervenção visando o incremento da sua eficiência alocativa.

An alternative ICU staffing model: implementation of the non-physician provider.

INTRODUCTION: Literature in Europe regarding implementation of nurse practitioners or physician assistants in the intensive care unit (ICU) is lacking, while some available studies indicate that this concept can improve the quality of care and overcome physician shortages on ICUs. The aim of this study is to provide insight on how a Dutch ICU implemented non-physician providers (NPP), besides residents, and what this staffing model adds to the care on the ICU. METHODS: This paper defines the training course and job description of NPPs on a Dutch ICU. It describes the number and quality of invasive interventions performed by NPPs, residents, and intensivists during the years 2015 and 2016. Salary scales of NPPs and residents are provided to describe potential cost-effectiveness. RESULTS: The tasks of NPPs on the ICU are equal to those of the residents. Analysis of the invasive interventions performed by NPPs showed an incidence of central venous catheter insertion for NPPs of 20 per fulltime equivalent (FTE) and for residents 4.3 per FTE in one year. For arterial catheters the NPP inserted 61.7 per FTE and the residents inserted 11.8 per FTE. The complication rate of both groups was in line with recent literature. Regarding their salary: after five years in service an NPP earns more than a starting resident. CONCLUSION: This is the first European study which describes the role of NPPs on the ICU and shows that practical interventions normally performed by physicians can be performed with equal safety and quality by NPPs.

Hot Off the Press: Peripheral Intravenous Cannula Insertion and Use in the Emergency Department.

This is a prospective before-after study comparing peripheral intravenous cannulation (PIVC) placement and usage rates following a 10-week-long multimodal intervention provided to medical and nursing staff working in a tertiary emergency department (ED). The intervention focused on improving appropriate use of PIVCs in an emergency setting by emphasizing to clinicians that a PIVC should only be placed if it was believed there was more than an 80% chance that it would be used. Patients were eligible for the study if they presented to the ED and were >18 years of age. Patients were excluded from the study if they were triage category 1, already had a PIVC placed in an ambulance, or were transferred from another hospital. Among the 4,172 patients included in the analysis, there was a 9.8% reduction in the number of PIVCs inserted (95% confidence interval [CI] = 6.8-12.87) and a 12% increase in PIVC usage (95% CI = 8.7%-17.0%) in the postintervention cohort.

Prospective observational study of predicted usage of intravenous cannulas inserted in a tertiary paediatric emergency department.

OBJECTIVES: To determine the proportion of unused peripheral intravenous cannulas (PIVCs) inserted in a paediatric emergency department (PED) and to assess clinicians' abilities to predict future usage of PIVC. METHODS: Prospective concealed observational study in a tertiary PED. Healthcare workers (HCWs) completed questionnaires upon insertion and removal of PIVC with review of patient notes if required. The primary outcome was the number of unused, unnecessary PIVCs. Secondary outcomes included demographic factors affecting unused cannulas, a clinician's ability to predict PIVC use and the incidence of complications from PIVC insertion. RESULTS: From 806 returned questionnaires, 719 patients were recruited. Twenty-two per cent of PIVCs remained unused after initial insertion for all patients. There was no significant difference in the rate of unused cannulas among any age or sex category, with the lowest rate of unused PIVCs in triage category 2 patients. HCW seniority when deciding to insert a PIVC did not affect usage rates. Likert scale analyses showed that HCWs could correctly predict ongoing use of PIVCs in 90% of cases. The overall rate of PIVCs removed for infected or inflamed insertion sites was low at 0.8%. CONCLUSION: This study is consistent with the idle PIVC rates observed in PEDs but there is potential to further reduce this rate with targeted insertion. The paediatric clinicians' reliability in predicting PIVC use has been demonstrated for the first time and we have identified four groups where targeted phlebotomy rather than i.v. cannulation would reduce unused cannulas.

Outcomes, readmissions, and costs in transfemoral and alterative access transcatheter aortic valve replacement in the US Medicare population.

OBJECTIVE: To comprehensively evaluate and compare utilization, outcomes, and especially costs of transfemoral (TF), transapical (TA), and transaortic (TAO) transcatheter aortic valve replacement (TAVR). METHODS: All Medicare fee-for-service patients undergoing TF (n = 4065), TA (n = 691), or TAO (n = 274) TAVR between January 1, 2011, and November 30, 2012, were identified using Health Care Procedure Classification Codes present on Medicare claims. Hospital charges from Medicare claims were converted to costs using hospital-specific Medicare cost-to-charge ratios. RESULTS: TA and TAO patients were similar in age, race, and common comorbidities. Compared with TF patients, TA and TAO patients were more likely to be female and to have peripheral vascular disease, chronic lung disease, and renal failure. Thirty-day mortality rates were higher among TA and TAO patients than among TF patients (TA, 9.6%; TAO, 8.0%; TF, 5.0%; P < .001). Adjusted mortality beyond 1 year did not differ by access. TA patients were more likely to require cardiopulmonary bypass (CPB). Increased adjusted mortality was associated with CPB (hazard ratio, 2.13; P < .01) and increased 30-day cost ($62,000 [interquartile range (IQR)], $45,100-$86,400 versus $48,800 [IQR, $38,100-$62,900]; P < .01). Cost at 30 days was lowest for TF ($48,600) compared with TA ($49,800; P < .01) and TAO ($53,200; P = .03). CONCLUSIONS: For patients ineligible to receive TF TAVR, TAO and TA approaches offer similar clinical outcomes at similar cost with acceptable operative and 1-year survival, except for higher rates of CPB use in TA patients. CPB was associated with worse survival and increased costs.

Sex differences in utilization and outcomes of catheter-directed thrombolysis in patients with proximal lower extremity deep venous thrombosis - Insights from the Nationwide Inpatient Sample.

Catheter-directed thrombolysis (CDT) is being increasingly used for the treatment of proximal lower extremity (LE) deep venous thrombosis (DVT). However, sex differences in utilization and safety outcomes of CDT in these patients are unknown. The Nationwide Inpatient Sample (NIS) database was used to identify all patients with a principal discharge diagnosis of proximal LE or caval DVT who underwent CDT between January 2005 and December 2011 in the United States. We evaluated the comparative safety outcomes of CDT among a propensity-matched group of 1731 men versus 1731 women. Among 108,243 patients with proximal LE or caval DVT, 4826 patients (4.5%) underwent CDT. Overall, women underwent CDT less often compared to men (4.1% vs 4.9%, p<0.01, respectively). The rates of CDT increased between 2005 and 2011 for both women (2.1% to 5.9%, p<0.01) and men (2.5% to 7.5%, p<0.01). There was no significant difference in in-hospital mortality (1.2% vs 1.3%, p=0.76). Women were noted to have higher rates of blood transfusions (11.7% vs 8.8%, p<0.01), but lower rates of intracranial hemorrhage (0.5% vs 1.2%, p=0.03) and gastrointestinal bleeding (0.9% vs 2.2%, p<0.01) compared with men. Women were more likely to undergo inferior vena cava filter placement (37.0% vs 32.1%, p<0.01). In this large nationwide cohort, women with proximal DVT were less likely to receive CDT compared to men. Although mortality rates were similar, women were noted to have higher blood transfusion rates while men had more episodes of intracranial and gastrointestinal bleeding.

Contrast-induced nephropathy in patients undergoing endovascular peripheral vascular intervention: Incidence, risk factors, and outcomes as observed in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: The incidence, risk factors, and outcomes associated with Contrast-induced nephropathy (CIN) after Percutaneous Vascular Intervention (PVI) in contemporary medical practice are largely unknown. METHODS: A total of 13 126 patients undergoing PVI were included in the analysis. CIN was defined as an increase in serum creatinine from pre-PVI baseline to post-PVI peak Cr of ≥0.5 mg/dL. RESULTS: CIN occurred in 3% (400 patients) of the cohort, and 26 patients (6.5%) required dialysis. Independent predictors of CIN were high and low body weight, diabetes, heart failure, anemia, baseline renal dysfunction, critical limb ischemia, and a higher acuity of the PVI procedure and a contrast dose that was greater than three times the calculated creatinine clearance (CCC) (adjusted OR 1.4, 95% CI: 1.1-1.8, P = 0.003). CIN was strongly associated with adverse outcome including in-hospital death (adjusted OR 18.1, CI 10.7-30.6, P < 0.001), myocardial infarction (adjusted OR 16.2, CI 8.9-29.5, P < 0.001), transient ischemic attack/stroke (adjusted OR 5.5, CI 3.2-14.9, P = 0.001), vascular access complications (adjusted OR 3.4, CI 2.3-5, P < 0.001), and transfusion (adjusted OR 7, CI 5.4-9, P < 0.001). Hospital stay was longer in patients who developed CIN versus those who did not. CONCLUSIONS: CIN is not an uncommon complication associated with PVI, can be reliably predicted from pre-procedural variables, including a contrast dose of greater than three times the CCC and is strongly associated with the risk of in-hospital death, MI, stroke, transfusion, and increased hospital length of stay.

Establishing a Dedicated Difficult Vascular Access Team in the Emergency Department: A Needs Assessment.

Peripheral vascular access is one of the most common procedures performed in emergency departments across the United States. Successful venipuncture is critical in providing timely diagnosis and treatments for patients. The aim of this article is to describe a needs assessment performed in a level-one academic emergency department to establish the need for a dedicated team for patients with difficult vascular access. Results from this assessment suggest that difficult vascular access represents tangible threats to patient safety and increased use of resources.

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study.

BACKGROUND: Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy. METHODS: In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated. DISCUSSION: This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications. TRIAL REGISTRATION: Dutch trial registry: NTR6015 . Registered 9 August 2016.

Video-based Assessment of Peripheral Intravenous Catheter Insertion in the Resuscitation Area of a Pediatric Emergency Department.

OBJECTIVE: The objective was to describe the frequency of and factors associated with prolonged peripheral intravenous catheter (PIV) insertion in the resuscitation area of a pediatric emergency department (PED). METHODS: Video-based study of a consecutive sample of nontrauma patients undergoing PIV insertion in the resuscitation area of a PED. Preexisting videos were the main data source. The primary outcome was patients with prolonged duration of PIV insertion (>90 seconds from start of first attempt to successful flush/blood draw). Logistic regression identified variables independently associated with prolonged PIV insertion. RESULTS: A total of 151 consecutive nontrauma patients underwent PIV insertion during a 2.5-month period. Sixty-nine patients (46%) had prolonged PIV insertion, including 14 for whom PED providers failed to insert PIVs. For patients with successful PIV insertion by PED providers, median duration was 48 seconds (interquartile range [IQR] = 23 to 295 seconds). Vascular access was ultimately achieved for 13 patients (93%) with initial insertion failure by the PED team (10 non-PED personnel, three intraosseous lines), with a median duration of 26.7 minutes (IQR = 19.9 to 34.2 minutes). Age ≤ 2 years (ORadj = 6.9; 95% confidence interval [CI] = 2.9 to 16.1) and musculoskeletal contractures (ORadj = 5.3; 95% CI = 1.6 to 17.2) were independently associated with prolonged PIV insertion. CONCLUSIONS: Prolonged PIV insertion is common in a PED resuscitation area. When PED providers could not insert a PIV, time to insertion was very long. Young patients and those with contractures were at particular risk for prolonged and failed PIV placement. When emergent vascular access is required, alternative approaches should be considered early for these patients.

The prehospital intravenous access assessment: a prospective study on intravenous access failure and access delay in prehospital emergency medicine.

OBJECTIVES: Intravenous access in prehospital emergency care allows for early administration of medication and extended measures such as anaesthesia. Cannulation may, however, be difficult, and failure and resulting delay in treatment and transport may have negative effects on the patient. Therefore, our study aims to perform a concise assessment of the difficulties of prehospital venous cannulation. METHODS: We analysed 23 candidate predictor variables on peripheral venous cannulations in terms of cannulation failure and exceedance of a 2 min time threshold. Multivariate logistic regression models were fitted for variables of predictive value (P<0.25) and evaluated by the area under the curve (AUC>0.6) of their respective receiver operating characteristic curve. RESULTS: A total of 762 intravenous cannulations were enroled. In all, 22% of punctures failed on the first attempt and 13% of punctures exceeded 2 min. Model selection yielded a three-factor model (vein visibility without tourniquet, vein palpability with tourniquet and insufficient ambient lighting) of fair accuracy for the prediction of puncture failure (AUC=0.76) and a structurally congruent model of four factors (failure model factors plus vein visibility with tourniquet) for the exceedance of the 2 min threshold (AUC=0.80). CONCLUSION: Our study offers a simple assessment to identify cases of difficult intravenous access in prehospital emergency care. Of the numerous factors subjectively perceived as possibly exerting influences on cannulation, only the universal - not exclusive to emergency care - factors of lighting, vein visibility and palpability proved to be valid predictors of cannulation failure and exceedance of a 2 min threshold.

Intravenous access in the prehospital settings: What can be learned from point-of-injury experience.

BACKGROUND: Intravenous (IV) access has an essential role in the care provided for trauma patients, allowing for transfusion of blood products, fluids, and drugs. Decisions should be made regarding the necessity of IV access while considering cost-benefit of the procedure in terms of delayed evacuation times. METHODS: A retrospective review of all trauma patients in whom at least one attempt at IV access was performed were reviewed. Data were abstracted from the Israeli Defense Force Trauma Registry. RESULTS: Of 7,476 patients, 1,082 patients who had at least one documented attempt at IV access between January 1997 and April 2013 were included in this study. Overall cumulative success rate at IV access was 82%. Success rates for IV access were 86%, 68%, 63%, 50%, 20% for the first, second, third, fourth, and fifth attempts, respectively. The first and second attempts accounted for 96% of the successful procedures. Mortality in patients for whom IV access was successful was 13%; mortality in patients for whom IV access was not successful was 35%. CONCLUSION: The success rate of IV access declined with each subsequent attempt. There was minimal improvement of overall success rate seen after the second attempt. Our findings suggest that the inability to obtain peripheral venous access is associated with severe injuries. These finding support a policy of limiting the number of venous access attempts to two attempts, followed by a reevaluation of need for parenteral access. Improved training of combat medics and paramedics might marginally increase the success rates of IV access. Point-of-injury data, used for ongoing learning and research, form the ground for improving combat casualty care and thus help saving lives. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Have CT and MR Angiography Replaced Catheter Angiography in Diagnosing Peripheral Arterial Disease?

PURPOSE: To determine whether MR angiography (MRA) and CT angiography (CTA) have replaced diagnostic catheter angiography (DCA) in diagnosing peripheral arterial disease. METHODS: Medicare Part B databases for 2002-2013 were reviewed. Current Procedural Terminology codes for extremity MRA, CTA, and DCA were selected. Physician specialty codes were used to classify providers as radiologists, cardiologists, or surgeons. Utilization rates per 100,000 Medicare beneficiaries were calculated. RESULTS: Among all specialties, the combined utilization rate of all 3 types of angiography increased from 917 per 100,000 in 2002 to 1,261 in 2006 (+38%), after which it remained stable until 2010, and then declined to 1,010 in 2013. The overall rate of MRA and CTA together increased from 89 in 2002 to 440 in 2006 (+394%), after which it leveled off, and then gradually decreased to 331 in 2013. In 2013, 33% of the total procedures were MRA or CTA, up from 10% in 2002. Radiologists performed >85% of MRA and CTA examinations. Among radiologists, the DCA utilization rate decreased by 75% from 2002 to 2013, whereas among cardiologists and surgeons together, the overall DCA utilization rate increased by 64% from 2002 to 2010 before dropping somewhat in 2011. CONCLUSIONS: Among radiologists, MRA and CTA have replaced DCA in diagnosing peripheral arterial disease. Although overall utilization of DCA has remained steady, it has risen sharply among cardiologists and surgeons, while dropping sharply among radiologists. Given the increased utilization of DCA among cardiologists and surgeons despite noninvasive alternatives, self-referral continues to be of concern in the setting of increasing health care costs.

Brachial artery catheterization: an assessment of use patterns and associated complications.

BACKGROUND: Although studies have compared safety and outcomes of radial artery cannulation with other arterial catheterization locations, there is insufficient information describing brachial artery catheterization. In this study, we characterized the perioperative use patterns and the complication rates associated with brachial arterial catheterization and compared these outcomes with radial artery catheterization. METHODS: We performed a retrospective analysis of adult patients (age ≥18 years) undergoing surgical procedures at an academic medical center from January 1, 2008, to December 31, 2011. An institutional database containing information on anesthetic care was queried to identify all brachial artery catheterizations. Baseline characteristics, details relating to the surgical and catheterization procedures, and catheter-related complications were collected and compared with a random sample of patients receiving radial artery catheterization. RESULTS: We identified 858 patients receiving brachial catheterization perioperatively. An additional 3432 patients receiving radial catheterization were identified. Patients receiving brachial catheterization were more often women, had a lower body mass index, had more comorbidities, and had longer anesthetic and catheterization durations. Three vascular complications were identified in the cohort receiving brachial artery catheterization compared with 1 patient with a peripheral neuropathy in the radial artery catheterization cohort (unadjusted complication incidence [95% confidence intervals] brachial artery catheterization, 0.35% [0.12%-1.02%] vs radial artery catheterization, 0.03% [0.005%-0.16%], respectively; P = 0.030; relative risk [95% confidence interval] = 12.0 [1.7-83.4]). There were no catheter-related bloodstream infections. CONCLUSIONS: We found that brachial artery catheterization is used in more medically complex patients and for longer duration than radial artery catheterizations. Although the limited number of adverse outcomes precluded statistical adjustments in this investigation, the observed differences in complication rates between cannulation methods suggest that brachial artery catheterization may be a suitable alternative to radial artery catheterization in patients with complex medical comorbidities.

Phlebitis in amiodarone administration: incidence, contributing factors, and clinical implications.

BACKGROUND: Intravenous amiodarone is an important treatment for arrhythmias, but peripheral infusion is associated with direct irritation of vessel walls and phlebitis rates of 8% to 55%. Objectives To determine the incidence and factors contributing to the development of amiodarone-induced phlebitis in the coronary care unit in an academic medical center and to refine the current practice protocol. METHODS: Medical records from all adult patients during an 18-month period who received intravenous amiodarone while in the critical care unit were reviewed retrospectively. Route of administration, location, concentration, and duration of amiodarone therapy and factors associated with occurrence of phlebitis were examined. Descriptive statistics and regression methods were used to identify incidence and phlebitis factors. RESULTS: In the final sample of 105 patients, incidence of phlebitis was 40%, with a 50% recurrence rate. All cases of phlebitis occurred in patients given a total dose of 3 g via a peripheral catheter, and one-quarter of these cases (n = 10) developed at dosages less than 1 g. Pain, redness, and warmth were the most common indications of phlebitis. Total dosage given via a peripheral catheter, duration of infusion, and number of catheters were significantly associated with phlebitis. CONCLUSIONS: Amiodarone-induced phlebitis occurred in 40% of this sample at higher drug dosages. A new practice protocol resulted from this study. An outcome study is in progress.