| Abstract |
Background: Vascular access on the first attempt to a department such as the emergency department is critical. It is often the most crucial direct intervention since it supports vital functions and the maintenance of the patient’s life. It is a great challenge even for experienced health professionals, especially when patients arrive at the ED and are in a critical condition. Delays in the initiation of treatment, such as administration of antiarrhythmic or vasoconstrictive drugs, resuscitation fluids, or antibiotics to patients with sepsis, are directly related to hospital-acquired mortality. Identifying any factors that delay a patient’s peripheral vascular access to the ED is vital to improving care. Especially for patients who come to the ED with pain, the administration of analgesia through the intravenous route is an essential part of the patient’s care and a significant indicator of the quality of care provided. Failure to place a peripheral intravenous catheter, repeated attempts, and associated complications that may arise pose risks and cause additional costs to the healthcare system.
Objective: The identification of the prognostic factors of the patient, but also the characteristics of the healthcare professional that determine the increased risk of failure in the first attempt to place an intravenous catheter
Methods: This is a prospective study of patients who came to the Emergency Department of the University General Hospital of Heraklion (PAGNI) from July to November 2023. The study included a convenience sample of patients aged 18 and older who came to the ED and required a peripheral intravenous catheter placement. The nurses who agreed to participate in the study initially filled out a form with their characteristics, such as demographic characteristics, years of experience in the ED and non-ED, their level of education, venipuncture site preference, and venous catheter size selection. Then, they filled out a special form for each patient, recording their basic characteristics such as gender, age, weight (Kg), height (cm), body type, previous hospitalizations, venipuncture area characteristics, workplace characteristics, number of attempts, etc. The statistical analysis of the survey data was done with the help of the statistical applications program SPSS (version 26), x2, and Fisher’s Exact test for quality values. The correlation analysis was done using the Pearson correlation. The level of statistical significance in all cases was set to a criterion value p of less than 0.05.
Results: A total of 1007 patients were included in the study and 28 nurses. The overall success rate on the first attempt was 69.5% (699). For 20.3% (204) of patients, it took two attempts; for 6.5% (65), it took 3 attempts, and for the remaining 3.8% (38), it took more than 4 attempts. For the category of nurses, it appeared that the age group 20-30 years needed more than one effort to successfully place a venous catheter at a higher rate (42.1%) compared to the rest of the older age groups with a statistically significant result (p-value <0.001). An interesting finding of our study was that nurses with up to 2 years of experience in the ED had the highest rate of more than one attempt at 41.2%. However, nurses with more than two years of experience in the ED did not differ significantly from each other. Regarding patient characteristics, gender was an important factor. In female patients, failure to succeed in peripheral venous catheter with the first attempt happened in 35.2% compared to 25.5% in males (Fisher's exact test, p<0.001). Regarding the age of patients, there was a gradual increase in failure with increasing age. According to patients’ weight, it appeared that patients who weighed less than 60 kg and patients who were overweight >100 kg were the patients who required more than one attempt to successfully place a venous catheter at a rate of 40.7% and 39.6%, respectively with a statistically significant result with a p-value of 0.006. Similarly, according to the patient's BMI (Body Mass Index), it appeared that those who had a BMI of <20 as well as those who had a BMI >30 underwent more than a placement attempt at a rate of 44.2% and 45.2% respectively compared to 25.9% and 31.2% for BMI 21-25 and 26-30 respectively (p<0.001). Patients who had recently been hospitalized, especially those who had been hospitalized less than 7 days ago and those who had been hospitalized 7-14 days ago, were those who needed a higher percentage of more than an attempt to place a venous catheter. Failure was 40.4% and 57.5%, respectively, compared to patients who had been hospitalized more than 15 days ago or had not been hospitalized at all (p-value 0.001). Regarding other characteristics of patients, patients who were overwhelmed, patients who used intravenous drugs, patients with diabetes mellitus (DM), patients with cachexia, excitable patients but also uncooperative patients, patients with a history of difficult venipuncture also seem to have difficulty in placement on the first attempt with a statistically significant result as well as patients who are in shock.
Conclusion: The age of the nurses and their years of experience in the ED appeared to be the main factors responsible for the failure of venous access on the part of the nurses. Regarding patients, female gender, old age, history of difficult venipuncture, DM, weight (underweight, overweight), extreme BMI values (low, high), intravenous drug use, recent hospitalization, bedridden, edema in the extremities and shock are the main factors for vascular access failure with the first attempt. The findings from this study are expected to be useful for nurses and healthcare professionals responsible for vascular access placement and for designing and developing methods to improve admission rates on the first attempt.
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