Whats your "criteria" for starting iv access on a pt?

mrhunt

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So fairly straightforward but looking to see both sides of the story.

for me i feel like i sometimes lack consistency. Overall i look at my pt's and say: Do they need meds? do they need fluids? Do i think their complaint warrants IV access in case their condition deteriorates and they need meds or fluids later down the road during transport?

I know alot of medics who will say "well the hospital is gonna start one anyway so i'll just do it" and that seems kinda strange to me...

My inconsistencies come as far as.....A seizure pt who HAD a seizure? Absolutely iv access. A chest pain pt who is now asymptomatic? Absolutely iv access in case symptoms return.

but on cases of syncope if pt isnt exibiting any FURTHER cardiac symptoms aside from the syncope itself alot of times i wont. Or if i can do an ODT med such as oral zofran then i'll go that route since its the preferred method within our counties protocols.

Example: had a lady who fell 24 hour ago, hit her head. She said she was fine and called 911 a full 24 hour's later "to get checked out" cause her neighbor said she should. Pt had a long list of chronic complaints, non of which were in anyway involved in prior fall or head injury. hx of etoh abuse, no seizure hx, Pupils fine. No lethargy, vitals fine, sugar fine. pt was just chilling. She had chronic nausea / vomiting on a daily basis for MONTHS due to her diverticulitis.... No iv access. doesnt seem warranted at all.

We get her to the ER and she has a seizure the second we wheel her in. Since everything else basically ruled out it kinda appeared to be an (obvious in my mind) subdural. but even if i DID get iv access it wouldnt have changed the treatment. She was already in the er next to the bed we were placing her in while it happened so its not like i was pushing versed at that point and care was actively being transferred WHILE she seized and everyone witnessed it. Sure...iv access would have saved the nurses like 20 seconds but pt was out of the seizure by the time they had access OR meds were able to be drawn up anyways.

So.....what would u guys have done? What is your critera for iv access on your pt's?
 

NPO

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It's very case dependant. I prefer to have IV access, but I know what veins I can hit and I can't. If I'm not going to get the IV, I'm not going to poke them.

All emergency meds can be given via an alternate route if their condition changes. (I'm assuming they were well compensated/stable when I decided not to establish an IV)

Routine IV access is a convenience for me and the hospital.
 
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mrhunt

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we also have a hospital that tends to scoff if a pt has an iv that they want to go to triage or will scold medics for putting in an iv.

It doesnt change my treatment protocols whatsoever but its in the back of my mind. Ultimately its if i think my pt needs iv access while in MY care, and not in the hospitals care that matters.
 

Peak

ED/Prehospital Registered Nurse
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In the field I put IVs in critical patients or patients who require one for therapeutic intervention.

On the ED I don't care if EMS puts an IV in a stable patient. Chances are I'm going to need blood that wasn't drawn (and sometimes it just needs to be redrawn, especially with lactate and amonia), so I'm going to put in a second line the vast majority of the time (unless I need to do an art stick for some reason).

Right or wrong most hospital require field starts to be removed in 24 hours or less regardless, so the patient has a good chance of getting stuck again if they get admitted.
 

DesertMedic66

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Ground job: the county only wants us starting IVs on patients who are going to need medications or fluids during the prehospital setting or if it’s a critical patient.

Flight job:
BFB8979C-3C27-4877-8498-19FEE2CA2F03.jpeg

If you already have an IV we will probably be looking for a second. If you only have a 22G we will probably be looking to see if we can get something larger however most of our patient encounters are for critical/unstable patients.
 

NPO

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...however most of our patient encounters are for critical/unstable patients.
Really? It seems like at least 50% of patients flown around here are pretty stable. We just had one come in for "palpitations". Everything else was normal.
 

silver

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We get her to the ER and she has a seizure the second we wheel her in. Since everything else basically ruled out it kinda appeared to be an (obvious in my mind) subdural. but even if i DID get iv access it wouldnt have changed the treatment. She was already in the er next to the bed we were placing her in while it happened so its not like i was pushing versed at that point and care was actively being transferred WHILE she seized and everyone witnessed it. Sure...iv access would have saved the nurses like 20 seconds but pt was out of the seizure by the time they had access OR meds were able to be drawn up anyways.
Could have given it IM so really doesn't matter in that instance. Don't feel bad.
 

johnrsemt

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Good luck switching IV's on me; I don't like getting stuck, and if I have a good IV in me; it stays for 72 hours. I had that conversation with an ICU nurse: She was bound and determined that she was going to put a new IV in me, because they didn't like IV's that the ED started. I told her she was good them because mine was started in the mountains on the way to the hospital. I thought she was going to faint. I told her the only way she was going to put a new one in me was if the DON would come show it to me in writing in the hospital policy at 0200. The IV stayed for 66 more hours. The DON came in the next day and asked me if I was harassing her nurse and when I said yes she told me to keep up the good work.

To answer the original question though: I put at least 1 IV in almost every patient I transport: but our transport distances for my FT job is 45-90 miles minimum and may be an additional 60 miles and we don't transport BS patients (I have had 1 BS patient in 12 years here).
PT job is 105-130 miles from base and can be up to an additional 100 miles, maybe 50 of that dirt and gravel roads: again we don't get a lot of BS patients; a lot of critical patients. I put 2 IV's in probably 25% of patients and try to get 2 in every one I fly; and it might be over an hour before we can meet a helicopter.
 

Peak

ED/Prehospital Registered Nurse
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Good luck switching IV's on me; I don't like getting stuck, and if I have a good IV in me; it stays for 72 hours. I had that conversation with an ICU nurse: She was bound and determined that she was going to put a new IV in me, because they didn't like IV's that the ED started. I told her she was good them because mine was started in the mountains on the way to the hospital. I thought she was going to faint. I told her the only way she was going to put a new one in me was if the DON would come show it to me in writing in the hospital policy at 0200. The IV stayed for 66 more hours. The DON came in the next day and asked me if I was harassing her nurse and when I said yes she told me to keep up the good work.

To answer the original question though: I put at least 1 IV in almost every patient I transport: but our transport distances for my FT job is 45-90 miles minimum and may be an additional 60 miles and we don't transport BS patients (I have had 1 BS patient in 12 years here).
PT job is 105-130 miles from base and can be up to an additional 100 miles, maybe 50 of that dirt and gravel roads: again we don't get a lot of BS patients; a lot of critical patients. I put 2 IV's in probably 25% of patients and try to get 2 in every one I fly; and it might be over an hour before we can meet a helicopter.
There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.

Where are you that a hospital has a director of nursing? DONs are a nursing home thing.
 

DesertMedic66

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There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.

Where are you that a hospital has a director of nursing? DONs are a nursing home thing.
One of the hospitals that I am pretty familiar with in SoCal (trauma, STEMI, stroke) has a DON.
 

Aprz

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It is such a low risk procedure, very likely to be done at some point of the patient care process whether by us or not, I don't get why people worry themselves over whether they should do it or not. If you believe the patient at some point will need it, whether you are going to use it or not, I say do it.
 

akflightmedic

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There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.

Where are you that a hospital has a director of nursing? DONs are a nursing home thing.

Standard around here is 96 hours for IV, then start thinking about changing it IF indicated. Usually, by the time 4 days have come and gone, they are either having the IV removed and prepping for discharge or they have had a mid line placed.

As for DON, quite common...many DONs here in the area hospitals.
(State of Maine for reference)
 

Peak

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I've had IVs last for weeks on some kids, a handful have lasted over a month. There is no need to pull them early.
 

Peak

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In the places I've worked we have CNOs and ACNOs. There are directors of services (emergency, trauma, transplant, et cetera), but not of 'nursing' in the hospital. Directors are typically an operational term.
 

GMCmedic

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One of our local hospitals started a policy where they refused to use prehospital IVs, thats when I really started paying attention to what I did and did not start IVs on.

If the patient was stable, I assed veins and felt confident that I could get an IV fairly quickly if needed, the complaint was relatively non emergent, and I foresaw no need for fluids or medication, I did not start and IV.

Now everyone gets an IV or typically already has one. I havent attempted an IV start since October of 2018.
 

johnrsemt

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Where I used to work, when I worked private service we used to do a lot of small hospital to larger hospital for cardiac cath etc. 1 particular hospital was really bad about sending out patients with a good patent 22 or 24 g IV site. I would almost always put a larger IV in them during the early part of the 30 mile transport: 2 reasons: 1: if the patient was going to have a cardiac procedure done there was a decent, but small chance that they would crash on me and push ACLS drugs through a 24 g IV sucks. 2: Cath labs like at least a 20 g, if not bigger. Surprising how many of the Cath lab docs would let my partner and I stay and watch the procedures since we helped them get a head start on the Procedure. 1 doctor would take us to lunch at least once a month for doing that.
 

Akulahawk

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Around here, our prehospital guidelines are reasonably specific about which patients will get a line and which ones won't. Basically if your patient needs to be given medication via IV or your specific protocol you're working from states that an IV must be placed, then the patient gets a line. If your patient doesn't need IV meds or you're not working from a protocol that requires IV access, you don't place the line. The medics are NOT allowed to place IV's for "precautionary" reasons. Nearly every patient that lands in an ED bed will get a line. If you end up in a chair (because you're not that sick) then you won't get one. It's a VERY rare shift that I don't put in an IV, let alone less than 2-3, as I'm one of the "go-to's" for the difficult sticks (I also do US guided sticks).

Also, one of the "nicer" things about our IV catheters is that they do have a pretty high flow rate. They're a PITA to place sometimes, but they have a slightly higher flow rate than the previous catheters and ours are pressure rated so we can do CT Angio procedures with a 22g placed instead of a 20g.

At least I have reasonable discretion about how many IVs to place once IV access is ordered...
 

Peak

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Also, one of the "nicer" things about our IV catheters is that they do have a pretty high flow rate. They're a PITA to place sometimes, but they have a slightly higher flow rate than the previous catheters and ours are pressure rated so we can do CT Angio procedures with a 22g placed instead of a 20g.
Are you using the diffusics?
 

Akulahawk

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Are you using the diffusics?
Yep. Hate to place 'em but once they're in, the flow rate is pretty decently good.

Added bonus: they don't dribble blood...
 

Peak

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Yep. Hate to place 'em but once they're in, the flow rate is pretty decently good.

Added bonus: they don't dribble blood...
I've only used the regular nexivas, I like them for EJs and patients with HIV or hepatitis. I refuse to use them on kids though, you just can't feel the same with them.

Do you find that the diffusics still flow quicker with blood or albumin?
 
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