This document discusses the implementation of an EMT mid-line team at UF Health Jacksonville to reduce central line-associated bloodstream infections (CLABSIs). It describes how EMTs in the emergency department were trained to place ultrasound-guided peripheral IV lines, which led to an 80% reduction in central line placements. The success of this program then prompted the creation of an EMT mid-line team to place mid-lines in intensive care unit patients to further reduce CLABSI rates across the hospital. Key aspects of implementing this team included developing an EMT training program, ensuring continuity of ultrasound equipment, tracking placement success rates, and changing policies to allow peripheral mid-lines to remain in place for up to 29 days.

1. IMPROVING PATIENT SAFETY
& PATIENT OUTCOMES
EMT SUPPORT TEAM
UF Health Jacksonville
Cynthia Gerdik DNP, MBA, RN, NE-BC, TCRN
AVP Nursing UF Health Jacksonville

2. Disclosure information
I have no conflicts of interest
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3. Learning Objectives
As a result of attending this session, the learner will be able:
• Distinguish the value of a non-RN team to reduce CLABSIs
• Describe the newest technology associated with mid-lines
• Apply implementation strategy for an ultrasound-guided EMT mid-line team to
reduce CLABSIs
• Avoid pitfalls from implementation to success
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4. BACKGROUND
• University of Florida-Health
– Academic Urban Emergency Department, Level I Trauma Center
– Emergency Medicine Residency
• Central Line Associated Blood Stream Infection (CLABSI) rate high
– CVL infection control training lacks impact in infection rates
– Large number of CVLs placed in non-critically ill patients
 What if we decrease the number of CVLs placed?
 Target the front lines: ED EMTs
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5. EMT
attempt
IV x 3
Unable to
establish
IV
Nurse or
other EMT
attempt IV
CVC,
IO or EJ
IV
established
Notify MD
ED IV
access
Flowchart
USGPIV
CLABSI!!!

6. EMT
attempt
blind PIV
Unable to
establish
PIV, Notify
MD
ED Tech
attempts
USGPIV
Physician
places
CVL
PIV
established
Unable to
establish
USGPIV,
Notify MD
EJ or IO
established
ED EMT
placed
USGPIV

7. Can EMTs be Trained to Place USGPIVs?
USGPIV have low infection rates
• Trained 2 EMTs
–Limited US education
–Highly successful
–Implementation of USGPIV program
–Physicians and EMTs trained
–Reduction of CVL by 80%
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8. 8
Can EMTs be Trained to Place USGPIVs?

9. EMT Training Program Created
USGPIV Training Program
•Focused on IV access skill
•Limited ultrasound knowledge
•Course created with skills
competency
•Table created for quick
reference
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• Training Course
–Pre-test
–Lecture
–Post-test
–Skills lab
• Preceptor/Super User Competency
–5 successful lines
–Super User able to correct during
procedure to ensure success

10. COMPETENCY CHECK LIST
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11. Strategies for Continuity of Equipment
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12. USGPIV Training
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Initial Training during Annual ED
EMT Competency Training
•Voluntary additional training
•14 EMTs completed the
competency
•Each USGPIV attempt required
the completion of a QA form to
track success rates

13. Success Rates of EMT USGPIV Placement Compared to Other USGPIV Studies
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14. Published Research
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Duran-Gehring, et al. Improved Training in Ultrasound
Guided Peripheral Intravenous Catheter Placement Results
in Physician level Success for Emergency Department
Technicians. Journal of Ultrasound in Medicine. 2017

15. 23
39
23
21
28
31 32
21
17
8 8 8
5
8
10
16
0
5
10
15
20
25
30
35
40
45
Q1
2014
Q2
2014
Q3
2014
Q4
2014
Q1
2015
Q2
2015
Q3
2015
Q4
2015
Q1
2016
Q2
2016
Q3
2016
Q4
2016
Q1
2017
Q2
2017
Q3
2017
Q4
2017
#CLABSIs
Quarter
UF Health Jacksonville # CLABSIs by Quarter 2014-
December2017
# CLABSIs by Quarter 2014- December 2017

16. # CLABSIs and Rate Data January 2013-December 2017
98
116
103
43
39
3.22
3.78
4.9
1.94 1.93
0
1
2
3
4
5
6
0
20
40
60
80
100
120
140
2013 2014 2015 2016 2017
CLABSIrateper1000centralline
days
#CLABSIs
UF Health Jacksonville # CLABSI and Rate January 2013-December
2017
# of CLABSIs
CLABSI Rate

17. # CLABSIs and Rate July 2016-December 2017
0
1
2
3
4
5
6
7
-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Jul-16 Aug-16Sep-16 Oct-16Nov-16Dec-16 Jan-17 Feb-17Mar-17Apr-17May-17Jun-17 Jul-17 Aug-17Sep-17 Oct-17Nov-17Dec-17
#ofCLABSIs
Ratesper1,000ptdays
UF Health Jacksonville # CLABSIs and Rate July 2016- December
2017# of CLABSIs
CLABSI rate per 1000 central line days

18. CLASBI Line Days
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19. Moving Forward
• USGPIV training mandated to all ED EMTs
–On-line course created
–EMT super user taught
• “Consults” from the inpatient floors and
ICUs for IV placement
• Creation of an ED IV team
–Dedicated US machine x3
–EMR order set
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20. Innovation: Utilize EMTs to Reduce CLABSI’s in
the In-Patient Nursing Units
• Asked to develop a PICC line team to help reduce CLASBI’s in the in-patient
nursing units.
• Reviewed literature first and discovered the new technology with midlines.
• EMT’s in the ED has previously been trained to insert ultrasound guided
peripheral lines.
• Decision was made to leverage the EMT training and develop a EMT midline
team.
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21. Mid-line Technology
• Midlines are not new, having power-injectable mid-lines was new
• Having a power injectable peripheral line for radiological diagnostics that
could stay in 29 days was really new
• Proposal was presented to the nursing executive team and to the
multidisciplinary critical care committee and approved as a pilot
• IV policy was changed to include peripheral midlines inserted by ultrasound
guided technology could stay in 29 days, but could not have chemo, pressors
or TPN administered through them.
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22. Guidelines for Midlines
• No TPN, chemo or pressors can be administered
• All ICU patients in the ED to have a mid-line inserted. Once pressors
were discontinued, and there was no need for TPN or chemo, CVL’s
were removed and the midlines was used in many ICU patients.
• Evolved into using fewer CVL’s in many ICU patients because the
mid-line provided a stable line for 29 days.
• Developed a nurse driven protocol to have the RN discontinue the
CVL without a physician order
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23. Leveraging EMT’s and Sonography
Technology
• EMTs insert peripheral lines every day across the United States in
backs of moving trucks.
• As the “experts of inserting peripheral lines, providing ultrasound
technology to improve their peripheral IV insertions skills made
sense.
• Cost comparison, RN PICC team with 4.2 FTE’s is $288,200 per
year. EMT mid-line team with 4.2 FTE’s is $117,900 per year
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24. Some “Take Always”
• Do your homework, review the literature more than 1,900 research
articles presented each day.
• Evolving into proactive rounding of all mid-lines daily in the hospital to
ensure dressings are in place and measure arm circumference. If
greater than 2cm from previous the primary RN is alerted.
• Physician order set needs to have reason for midline and an
alternative order for USGPIV, and do not allow blood draws from the
line
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25. COMMUNICATE & COMMUNICATE AGAIN
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26. QUESTIONS?
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