Unused peripheral intravenous catheters—is it all in ‘vein’?
Peripheral intravenous catheters (PIVCs) are invasive devices that are widely used by paramedics for the administration of intravenous (IV) therapy; however, adverse events including PIVC-associated bloodstream infection and increased on-scene times have been well documented. This study sought to investigate the incidence of paramedic-inserted PIVCs, unused PIVCs, and factors that influenced practice.
The study team conducted a retrospective review of electronic patient care records (ePCRs) of all patients attended to by St John Western Australia between 1 January and 31 December 2020. In this ambulance service, the decision to insert a PIVC is guided by the service's clinical practice guidelines, however, is largely an autonomous decision by the paramedic. All emergency calls and paramedic interhospital transfers were included but non-urgent patients were not.
Data on 11 variables were extracted from the ePCRs and categorised into patient, environmental, and paramedic characteristics. Details of the variables are within the article. The team used binomial logistical regression models to evaluate the combined impact of the variables for PIVC insertion and unused PIVCs.
Of 187 585 patients, 20.3% had a PIVC inserted. The unused PIVC rate was 44% (n=16 792), with the rates being higher in males (53.2%), and in patients aged 65–84 (50.8%) and 85+ years (50.3%). The highest unused rates proportionally per complaint were in respiratory (74%), cardiac (65%), and neurological conditions (59.8%).
Catheters inserted by more recently qualified staff were most likely to be unused (49%, n=3801 and 49.3%, n=2744, respectively) compared to the lowest frequency in those with 10+ years of experience (44.3%, n=6907).
Multiple variables were identified for the unnecessary insertion of PIVCs, many of which could be addressed through better education and mentoring of paramedics supported by clearer clinical guidelines. The study is Australian so may be different to the UK; however, the findings should encourage reflection on practice by UK paramedics.
Does the JRCALC age-per-page make paediatric drug calculations child's play?
The potential for drug errors in the prehospital environment is high due to the uncontrolled environment, urgency of intervention and changing status of the patient. When dealing with children, the risk increases because of the need to ensure the correct dose by body weight. JRCALC helpfully provides an age-per-page drug dose reference; however, evidence from America suggests that this is not enough to eradicate dosage errors.
Prior to this study, work in Michigan found an overall medication error rate relating to paediatric drug administration by emergency medical services (EMS) to be 34.7%. To reduce these errors, the state of Michigan implemented a paediatric dosing reference that had been developed to address known issues related to weight-based medication dose calculations.
The need for mathematical calculations was eliminated as the drug dose was provided in milligrams (mg), along with the volume to be administered in millilitres (ml). Additionally, the reference was colour-coded to match the Broselow-Luten Paediatric Emergency Medicine Tape.
To establish the effect of this dosing reference, the authors conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤12 years of age treated by 16 EMS agencies. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the paediatric dosing reference. During the study period, there were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3–48.4]). Notably, 17 drugs were given via the wrong route, including a case of 1:1000 epinephrine administered IV.
This study shows that on its own, a drugs dosing reference is not enough. The authors concluded that four key areas were likely contributory factors to medication dosing errors in this population: lack of sufficient paediatric education, limited paediatric encounters, limited medication administrations in the paediatric population, and weight-based dosing.