Difficult intravenous access as an independent predictor of delayed care and prolonged length of stay in the emergency department

Hamid Shokoohi; Michael A Loesche; Nicole M Duggan; Andrew S Liteplo; Calvin Huang; Ahad A Al Saud; Dustin McEvoy; Shan W Liu; Sayon Dutta

doi:10.1002/emp2.12222

Difficult intravenous access as an independent predictor of delayed care and prolonged length of stay in the emergency department

J Am Coll Emerg Physicians Open. 2020 Aug 19;1(6):1660-1668. doi: 10.1002/emp2.12222. eCollection 2020 Dec.

Authors

Hamid Shokoohi¹, Michael A Loesche², Nicole M Duggan², Andrew S Liteplo¹, Calvin Huang¹, Ahad A Al Saud³, Dustin McEvoy⁴, Shan W Liu¹, Sayon Dutta¹

Affiliations

¹ Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA.
² Department of Emergency Medicine Massachusetts General Hospital Harvard Affiliated Emergency Medicine Residency Program Boston Massachusetts USA.
³ Division of Emergency Ultrasound Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA.
⁴ Clinical Data Analyst Partners HealthCare Somerville Massachusetts USA.

Abstract

Objectives: Difficult intravenous access (DIVA) is common in the emergency department (ED). We investigated the extent to which DIVA is associated with care delay outcomes including time to first laboratory draw, therapies, imaging, and ED disposition.

Methods: An observational retrospective cohort analysis of patients with DIVA treated between 2018 and 2020 at 2 urban academic EDs was performed. DIVA was defined as patients requiring ultrasound-guided intravenous access placed by physicians or advanced practice providers (APPs) as opposed to landmark-based intravenous placement by nurses. ED throughput variables and disposition time were compared. We correlated DIVA with time to administration of intravenous pain medications, fluids, imaging contrast, laboratory results, and ED disposition.

Results: A total of 108,256 subjects with 161,122 total encounters were included. DIVA occurred in 4961 (3.1%) of ED visits. Patients with DIVA were more likely to be female (3.5% vs 2.6% for males, odds ratio [OR] 1.34, 95% confidence interval [CI]: 1.27-1.42), self-identify as black (OR 1.78, 95% CI: 1.66-1.91), and have higher acuity of illness (P < 0.001). Among pediatric patients, DIVA occurred most often in the first year of life at a rate of 3.25%. In adults, DIVA occurred in 2 age peaks; at 35 years (4.02%), and at 63 years (3.44%). In all workflow metrics, the presence of DIVA was associated with significant delays in median time to completion: 50 minutes for pain medication administration, 36 minutes for intravenous fluid administration, 29 minutes for laboratory results, 57 minutes for intravenous contrast administration, and 87 minutes for discharge orders.

Conclusion: DIVA was associated with increased time to therapies, diagnostic studies, imaging completion, and ED disposition. A more expeditious approach to achieving intravenous access in patients with predicted DIVA could improve ED throughput and patient care overall.

Keywords: care delay; emergency department; intravenous access; length of stay; point‐of‐care ultrasound; ultrasound; ultrasound‐guided.