Use of a Systematic Intervention Plan to Improve Compliance of Intravenous Access in Acute Gastrointestinal Bleeding

Abstract

Introduction: Gastrointestinal bleeding (GIB) is a common clinical presentation and carries substantial morbidity and mortality. While the available literature recommends placement of 2 large bore intravenous lines (2LBIV) in every patient presenting with GIB, the adherence and impact of this recommendation has never before been reported. We designed a quality improvement project to assess whether the patients presenting to our hospital with symptoms consistent with acute GIB have appropriate intravenous (IV) access or not. Our goal was to improve adherence to 2LBIV lines in patients with acute GIB. We hypothesized that appropriate IV access in acute GIB patients will result in reduction in length of stay, transfers to higher levels of care, mortality, and number of blood transfusions received.Table: Comparison of Outcomes in Pre and Post Intervention Group.Methods: We conducted a prospective, observational study, of all patients presenting to our emergency department with overt GIB over a 2 month period. Data analysis was performed and based on results, an intervention plan was developed, and executed. Post-intervention data collection was done over a three month period. Our interventions included physician and nursing education, placing posters in the emergency department, and creation of an order set in the electronic medical record system. Results: A total of 46 patients were in the pre-intervention group and 71 patients were in the postintervention group. The presence of 2LBIV lines in the pre-intervention group was only 19.5%, which improved to 36.6% in the post-intervention group (p=0.049). Outcomes between pre and post-intervention group are compared in table 1. Conclusion: The relatively simple and cost-effective intervention of placing 2LBIV lines is not often executed. Our investigation suggests that patients with GIB who are more critical are likely to get 2LBIV lines, i.e. patients admitted to the ICU, patients with acute kidney injury and those with lower blood pressures on presentation. A systematic multi-directional intervention strategy can improve compliance with 2LBIV lines, which is the basic first step in management of acute GIB patients. We suggest that specific mention of 2LBIV placement in guidelines from national societies like the American College of Gastroenterology (ACG) might improve compliance in this aspect.