Dana Goforth, RN, BSN; Dan Lantos, RN, MSN, CNML; Nick Leary, RN, BSN, PCCN, CCRN; Cindy Brenton, RN, MSN, NEA-BC.

1. Arming the Rapid Response Team with Intraosseous Needles Reduces
Time to First Medication and Improves Post-Code Survival to ICU Transfer
Carolinas Medical Center,
a facility of Carolinas HealthCare System,
has been Magnet® designated since 2013
Dana Goforth, RN, BSN, Dan Lantos, RN, MSN, CNML, Cindy Brenton, RN, MSN, NEA-BC, Nick Leary, RN, BSN, PCCN, CCRN
Carolinas Medical Center, Medical Intensive Care Unit, 1000 Blythe Blvd., Charlotte, NC 28203
Background
Intraosseous Vascular Access Devices (“IO” needles) are
commonly used in prehospital and Emergency Department
settings, but less often utilized in the inpatient arena.
Inpatient codes and rapid response situations may still
require emergent vascular access, however, and IO needles
can provide access more quickly than traditional IV or
central line placement. It was believed that training the
Rapid Response Team in IO placement could reduce “Time
to First Medication,” and therefore improve survival until ICU
transfer among patients who suffer a cardiac arrest without
functional vascular access. The Rapid Response Team at
Carolinas Medical Center in Charlotte, NC was trained and
incorporated IO needles into their practice in 2013.
Intraosseous access is often misunderstood among medical
professionals who are not familiar with the therapy. The IO route is
versatile in critical and unstable situations: most IV drugs and
fluids needed in an emergency have been shown to be safe
through IO delivery. This includes normal saline, dextrose (10%,
25%, and 50%), sodium bicarbonate, all ACLS drugs, vasoactive
medications, sedatives, paralytics, and multiple antibiotics. IO
access is also reliable for many laboratory tests, including
hemoglobin and hematocrit, glucose, BUN, and creatinine.
However, several chemical markers including sodium, potassium,
and venous blood gases, are not accurate when drawn from an
intraosseous device.
All ten members of the Rapid Response Team achieved
competency with IO needle placement following didactic
instruction and a hands-on cadaver lab. The one-day training
consisted of several work stations to familiarize staff with the use
of the insertion device, proper technique, and accurate
identification of anatomical landmarks. The hands-on training
began with staff practicing on eggs, to teach how little pressure is
needed for insertion. The team then moved to a skill station using
artificial bones, which taught the identification of the underlying
bony structures and drilling into the correct location on the bone.
Finally, the team practiced on cadavers in multiple stations to
experience drilling into real tissues and bone. Cadavers were
available for each anatomical insertion site to be practiced. One
cadaver was also dissected to show that the flow from the right
humeral head placement was superior to all other locations. At the
end of the cadaver lab training, each member of the team was
validated on their proficiency of IO placement in accordance with
the facility's policy.
Prior to this training, hospital policy already permitted IO
placement in “emergency situations,” so no modification of policy
was needed to adopt the new practice.
Education and Training
Usage Considerations
Per hospital policy, vascular access devices inserted under
emergent circumstances must be replaced within 24 hours.
Under the assumption that any line placed during a code
has a maximum usable life of 24 hours, IO needles
represent a small cost saving relative to central lines. The IO
kit is approximately $20 less expensive than a central line
tray, suggesting a cost savings of about $400 per year when
used for this indication.
A drawback of IO needles is that they offer only one lumen
for administration of fluids and medication, whereas the
acuity of a coding patient often calls for more than one
lumen of access. In situations where multiple ports are
needed, clinical judgment must be used to determine
whether a multi-lumen catheter can be placed under sterile
and controlled circumstances, or whether that line must be
placed emergently as well. The placement of an IO device
should not interfere with central line insertion and likely
offers more rapid vascular access than a central line alone.
Results
Conclusions/Recommendations
Analysis of “Time to first medication” and “Survival to ICU Transfer” data
suggests that patients who suffer a cardiac arrest without existing vascular
access may benefit when an IO needle is placed. In the cases reviewed,
vascular access was obtained more quickly and patients were more likely to
survive long enough to be transferred to an ICU when an IO was placed
instead of a peripheral or central line.
Certain logistical considerations may affect how other facilities weigh the
feasibility of adopting IO needle placement as part of the emergency response.
Initial training of staff in the insertion and management of IO devices is time
and labor-intensive, and the relatively infrequent occurrence of a code without
IV access can affect the ongoing competency of each staff member in IO
placement. Adopting this practice is likely to be most beneficial when the skill
can be “owned” by a small but consistent group of people, or in a facility where
codes without existing IV access are more likely.
N=26
3.42
1.78
0
1
2
3
4
No IO placed (N=17) IO placed (N=26)
Time(minutes)
All patients who coded without working vascular access, April 2013 - December 2014
Time to First Medication
52.9%
84.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
No IO placed (N=17) IO placed (N=26)
%ofpatientswhosurviveduntiltransfertoICU
All patients who coded without working vascular access, April 2013 - December 2014
Post-Code Survival to ICU Transfer
Records were reviewed from all non-ICU inpatient codes between April 2013 (the inception of
the facility’s standalone Rapid Response team) and December 2014. A total of 43 codes were
identified where the patient did not have functional vascular access at the time of the arrest. In
seventeen patients, access was obtained peripherally or via a physician-placed central line;
twenty-six patients received IO needles placed by the Rapid Response Team.
In the group that received IO needles, the mean time elapsed to administer the first ACLS
medication was 1.78 minutes, as compared to 3.42 minutes in the non-IO group, an average
reduction of 1 minute and 38 seconds (47.9%, p<0.001).
Among the group that received IO needles, 22 of 26 (84.6%) survived long enough to be
transferred to ICU, as compared with 9 of 17 patients (52.9%) who did not receive IO access.
This is a 59.9% improvement as compared to the non-IO group (p=0.02).
http://www.teleflex.com/en/usa/ezioeducation/index.html