Obtaining adequate vascular access is an imperative for successful resuscitation during clinical emergencies. Several features make obtaining central venous access challenging—anatomical guidance is limited without a pulse, physical movement during cardiopulmonary resuscitation impairs coordination, and the procedure occupies substantial space and sustained clinician attention. Intraosseous (IO) access, well-established in emergency department (ED) and field rescue, offers an expedient alternative, which avoids many of these obstacles. In recent literature, barriers to placing IO access in adults were described as physician's knowledge deficit regarding IO indications, nurses who were unfamiliar with the device and the lack of nursing support.1 Voigt et al2 recommend delegating champions and increasing awareness by developing clinical guidelines and indications for IO use.
It was suspected that patients requiring immediate vascular access for cardiopulmonary resuscitation or in the setting of a rapid response may be experiencing delays in resuscitation, due to vascular access challenges. This patient safety concern prompted an urgent review of current in house resuscitation practices. Review of index cases that included unsuccessful or prolonged attempts at venous access demonstrated that alternative access methods would have been considered if available.
Our institution's initial state had IO access available to the flight crew and providers in the ED, including the trauma bay, utilized almost exclusively for out of hospital cardiac arrest patients. On occasion, the ED provider was being summoned to the inpatient units for the placement of an IO access device as a life-saving measure. These requests for remote delivery were problematic due to competing ED-based emergencies and, most significantly, substantial delays associated with prolonged travel time given our large institutional footprint.
Intraosseous access utilization opportunities spanned medical surgical floors, intensive care units, and outpatient settings. The expansive geography and varied resuscitative providers emphasized our institutional need to standardize the availability of equipment, guidelines for device use, and the education and training of providers.2–12
After further review of current IO literature, Advance Cardiac Life Support (ACLS) and Advance Trauma Life Support guidelines, position statements from nursing organizations, and practice patterns within our own health system and those of our academic peers, it was determined that an IO access initiative should be considered for best practice for rescuing non–ED-based patients. To accomplish this, both hospital and nursing policies needed to be developed to guide practice patterns.
Proposing change can be difficult, especially in a large institution. Extensive stakeholders and clinical providers, including omnipresent trainees, presented unique challenges. To be successful, we suggest defining the following—what is needed, who are the stakeholders, where it is needed, and what is your time frame for beginning the process change.13–15
It is important to define the stakeholders and determine their position on the proposed project. This exercise aids to focus efforts on the necessary audience and emphasizes people and areas in need of more support. A stakeholder management process and analysis tool kit can be used by the project champions to accomplish this task. Success of process or policy implementation stems from the vested interest and directed leadership of the champions15–18 (Figure 1).
Specific investors included clinical providers from critical care units, emergency medicine and trauma, anesthesia, pharmacy, and radiology. In addition, governance bodies such as nursing shared governance and practice councils were also necessary to determine interest and potential support. Executive leadership was approached for allocation of funding and aid system wide change.14,15,19–21
POLICY DEVELOPMENT: CLINICAL GUIDELINES
To successfully develop a hospital and nursing policy, a clinical framework had to be constructed. This framework had to be sensitive to clinical indications, drugs employed, and training and competency assessments. To meet this demand, support and guidance were necessary from the following groups: regulatory, nursing, medicine, surgery, pharmacy and therapeutics, senior leadership, and the hospital board. Hospital and nursing policies were then drafted. The nursing IO policy was then reviewed by multiple nursing entities, including IO taskforce team, nursing practice council, nursing critical care committee, and regulatory. The hospital IO policy was brought before the hospital policy and regulatory committee, delegated faculty from various disciplines, and other entities in the health system prior to board review. Clinically, the greatest focus for standardization revolved around patient candidates for IO insertion, drugs available for use, IO dwell time, and IO training.
Pharmacy was recruited and a comprehensive literature review ensued. It was determined that, due to findings of inadequate high level of evidence, unsupported by the company, and limited human data, medications delivered via the IO route be limited to ACLS drugs, rapid sequence induction medications, intravenous fluids, and blood and blood products.4,5,22–26 These stakeholders became concerned for efficacy of medications and risk of injury through the IO space due to the higher viscosity and serum osmolarity levels of certain medications.3,7–9,23,27–31 They determined through literature review that medications like vasopressors, D50W, hypertonic saline, and antibiotics were controversial and unsupported for ongoing or prolonged use.1,3,12,27,28,32 As reported by the manufacturer, complication rates correlated to those discovered during literature review, less than 1% overall. Although very rare, complications from single-case studies reported the need for limb amputation from complications attributed to compartment syndrome from IO administration of medications and fluids.8,9,26,27,29,33,34 The majority of those reports were prior to newer technology and in pediatric patients. During this time it was noted that order entry was a limiting factor and that a list of medications was required to be provided to the information technology team so that the IO route could be associated with the medications to be delivered.
In response to more regulated use of the IO access and the medications safe for infusion, the hospital policy for IO use was written to reflect those concerns. Policy language was revised by stakeholders from vested parties (surgery, medicine, anesthesia, emergency medicine, nursing, and pharmacy). Controversy over medication use and dwell time continued disagreements between invested parties.31,35 After much collaboration between stakeholder, the Pharmacy and Therapeutics committee approved IO use as a bridge to vascular access until more definitive access could be established and limited the medications that could be infused through the IO and the duration of the device.3,12,22,23,25,28,29,31,34–36
An institutional decision was made regarding dwell time of the IO device. Although the IO device chosen (EZ-IO) is Food and Drug Administration approved for 24 hours, it was felt that IO access should be used solely for emergency rescue. In our institution, specialists thought that durable intravascular access can be obtained within 6 hours. By maintaining this short period, patients would have the least exposure to IO administration of drugs, which have limited safety data. Thus, due to safety concerns, the institution recommended a 6-hour or less dwell time. Each IO device would be a temporary access, and the clinical team should immediately begin plans to establish a peripheral intravenous catheter or central venous catheter. In situations of problematic access, the attending physician may extend use duration by additional 6-hour intervals to a maximum of 24 hours. This direction should be documented in the electronic medical record and an order placed by the primary team. The Pharmacy and Therapeutics committee approval yielded a draft policy that was then presented to the Medical Board (inpatient side) and Clinical Practices of the University Board (outpatient side) for final approval. Successful process implementation requires identifying hospital-based leadership responsible for key decisions such as regulatory, finance, and operations. This will ensure the ability to solidify unified policies throughout the health system, identify budgets for operational expenses, and standardize equipment.
Because this involved so many entities within our health system, an IO taskforce was established to streamline process improvements. A process improvement plan was established to ensure all involved parties were included. If a particular entity was mistakenly omitted from the initial planning phase, forward momentum was halted until that particular stakeholder's needs were addressed and incorporated into future plans.13,14,20,21,37
A tangible outline, process map, and a process timeline should be shared among the taskforce.38–41 These assist with keeping multiple team members on task and should be overseen by the champion. Updates to the taskforce should occur regularly and a meeting agenda and task assignment list distributed prior to each meeting (Figure 2).
COST HURDLES AND BUDGET DEVELOPMENT
Determining the health system infrastructure to develop budget and resource allocations of 3 entities (inpatient, outpatient, and radiology) was challenging. The large university hospital and its affiliated sites within the health system did not fall under enterprise purchasing. This meant that the allocation of cost had to be broken down and calculated for all 3 areas separately. The IO access system did not meet individual capital and therefore fell under each entities operational budget, which was reviewed on a quarterly basis. Intraosseous kits contained one 45 mm and one 25 mm needle set, 2 product-specific dressings, 1 power driver and reference card set. Forty six kits were purchased by nursing for the inpatient units, 13 were purchased by radiology and 36 were purchased for the outpatient clinical setting. All kits were placed in the bottom section of the code cart. Reordering supplies for each code cart was determined to be the responsibility of each individual unit. This also included the cost of the reference cards that was developed for each IO kit.
CONSISTENT MESSAGING: EDUCATION PLAN
ICU- and Non-ICU Based
Given the expansive nature of the IO audience, current knowledge gaps were analyzed and provider education and training deemed necessary. Practitioners were queried on their previous experience with IO access. It was identified that 81% of those who attended had no previous IO training. This reinforced the need for a formalized education and training program within the institution. It also identified the need to offer a skills refresher for those who attended training several months postimplementation, as this was a new skill to the majority of practitioners. It was determined that IO insertion did not rise to the level of high-risk skill requiring credentialing and therefore competency of hospital approved training would be sufficient. It was not surprising that providers had more experience with removal than insertion, as those caring for trauma patients, in the acute care setting, were more likely to have had exposure to this device postinsertion (Figure 3).
Prior to implementation, some providers had previous education and training supplied by the IO device manufacturer. We discovered this education to be biased. Accordingly, we developed a training course for our institution insertion providers and 1 for nursing staff who would be caring for, maintaining and removing the device. The insertion and removal portion included both knowledge and simulation teaching. This allowed for safe enactment of provider insertion simulation training.42–45 Simulation training was taught by the vendor until a hospital super-user and trainer was identified. A hospital IO champion was present for the skills sessions to ensure hospital specifics regarding hospital policy and procedures were communicated. Providers requiring education on insertion, care, maintenance, and removal included physicians, Advanced Practitioners (APs), ED and Critical Care nurses, Clinical Nurse Specialists, and Nursing Clinical Coordinators who respond to non–intensive care unit (ICU)-based clinical emergencies for both the inpatient and outpatient settings. Standardized training was twofold. Insertion providers were required to complete a skills simulation session and a didactic module, which included a narrated power point uploaded to the hospital intranet-based education learning system, Knowledge Link, and associated competency. Those nurses who would be caring for the device (ED, trauma, and ICU) were required to complete a skills simulation session for IO needle removal and a didactic module for care, maintenance, and removal with associated competency. When considering nursing and medical staff eligible for placement of an IO catheter, ACLS certification was determined to be essential (Figure 4).
Some concern was expressed regarding how nursing staff would know which physician or AP was trained in this skill. The addition of IO insertion training into the physician database will be a future consideration. A member from the nursing professional development and education team was assigned to the IO taskforce to assist with educational needs and roll out. To ensure that the nursing staff was “in the know” about the implementation of a new rescue device available on all the code carts, a nursing huddle was distributed to nursing units throughout the institution. Resources for staff reference on the intranet were updated to reflect institutional recommendations and guidelines. The “What's Hot” section on the hospital's intranet page also featured the device. Select nursing, AP, and physician staff were encouraged to participate in IO educational offerings yielding 263 personnel trained (Figure 5).
Implementation required developing a response plan for deployment of IO access. The plan involved 3 tiers. In the ICU tier, the critical care fellow or first responder and the AP would be trained in insertion, care, and removal. The non-ICU response tier was more complex as it enveloped both the inpatient and outpatient arenas. In the non-ICU setting the Nurse Clinical Coordinator was determined to be a consistent first responder and therefore would be primarily responsible for IO needle insertion if needed in this setting. As a backup for the Nurse Clinical Coordinator, the physician on the rapid response team could also be trained as an insertion provider. The ED was functional in the placement of the IO catheter prior to this implementation project, and its insertion team consisted of the ED attending or designated resident, designated nursing staff, and trauma faculty (Figure 6).
Once staff education was completed and the budget was approved, the champion disseminated the product information and assisted each department's leadership with the request to purchase. Products were delivered to and assembled by the champion to ensure consistency and completeness. The IO kit contained the case, 1 driver, one 25 mm needle kit, one 45 mm needle kit, 2 product-specific dressings, and reference cards. Once assembled, the leadership was informed and the IO kits were deployed to each care area with instructions on how to reorder supplies, where to place the kit, and contact information of the champion. Each care area with a code cart was responsible for placing the kit in the bottom drawer and relocking each cart. The new lock number along with the signature of the staff member was collected as proof of delivery.
Postdeployment it was imperative that there were designated personnel to ensure that the IO device was utilized per policy and within best practice standards. Insertion providers notified central personnel of the deployment of an IO device by completing a short survey tool used for performance improvement review. The information queried on this tool included date, indications for use, the number of attempts, location, type of insertion provider, infusions, patient disposition postevent, and complications (Figure 7). The results of utilization and compliance were contained in a secure database, analyzed and reported periodically to the code committee. If a deviation was identified, concurrent education could occur and any opportunities for improvement would be trended to verify loop closure had been established. Intraosseous skills refresher sessions were offered several months after initial education; this effort solidified knowledge retention. Staff provided favorable feedback that attendance of an IO skills refresher session was valuable and necessary.
Further research of this cohort is needed to determine whether IO access definitively attributed to favorable patient outcomes. Additional data collection was inhibited by the lack of a designated area for IO insertion time and location on the existing code sheet. Plans to improve IO documentation exist. Compliance with electronic medical record documentation in the acute care setting appeared to improve as communication regarding the new implementation of available IO-specific fields was developed and implemented.
Intraosseous practice patterns can differ between entities within health systems. Defining key stakeholders and gaining their support and culminating collaboration are important skills to effectively navigate unfamiliar heath system infrastructures.17,18 Utilizing a toolbox to organize a stakeholder analysis and developing a process map can add direction and focus. Embarking on implementing new policies and procedures will be unsuccessful without the help of experienced team members who can be called upon for guidance. These key individuals can assist in providing history, previous examples, and creating new contacts important to moving processes in a forward direction. A project can potentially lose momentum when a champion who maintains ownership is not present at important milestones. Effective communication is imperative to uncovering next steps and remaining goal oriented.15,40,41,46 Patience is an invaluable skill in this setting where it may be necessary to change institutional culture for process improvements. To gain others' confidence in your proposed policy or process change, collect supporting evidence and be able to articulate it. Gather all of the stakeholders together to form a taskforce to help brainstorm and streamline process development. Perform a cost analysis and align products with capital or operational budgets. Assess implementation strategies and develop a process map to demonstrate that a gap analysis was performed. Once the policy or product has been approved by the appropriate entity, effectively and consistently message and educate staff members regarding upcoming changes. Reevaluate and monitor the process and look for opportunities for future improvements.46–49 Persistence and preparation will help you to be successful in advocating for improvements in patient safety and quality patient care.
IO access may expedite resuscitative efforts in patients in extremis without venous access or where additional venous access is required for life-saving therapies.2–5,8,9,50 Standardizing placements of IO supplies decreased delays to IO placement and reduced institutional variability (Figure 7). Limiting IO dwell time may facilitate more timely definitive venous access. Champions for monitoring insertion setting, placement, and policy compliance are imperative for concurrent performance improvement and patient safety. Continued education and training by offering IO skill laboratory refreshers and annual e-learning didactic is suggested for maintaining proficiency and knowledge.42–45 The availability of IO access in the outpatient setting should be considered. More research opportunities exist to determine medication safety and efficacy in adult patients in the acute care setting.
* Intraosseous access may expedite resuscitative efforts in patients in extremis who lack venous access or where additional venous access is required for life-saving therapies.
* Standardizing placement of IO supplies decreased delays to IO placement and reduced institutional variability.
* Limiting IO dwell time may facilitate timely definitive venous access.
* Continued education and training by offering IO skill laboratory refreshers and annual e-learning didactic is suggested for maintaining proficiency and knowledge.
* Champions for monitoring insertion setting, placement, and policy compliance are imperative for concurrent performance improvement and patient safety.
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critical care rescue; intraosseous; intraosseous access; performance improvement; process mapping; stakeholder analysis