Emergency Department Technicians Research Articles

Operation STICK: A vascular access specialty program for the generalist emergency medicine clinician.

Comprehensive education and training programs are urgently needed to improve vascular access outcomes in the emergency department (ED). This study aimed to demonstrate the success of a formalized vascular access program in developing competent ED clinicians in traditional and ultrasound-guided insertion methods. This was a retrospective observational study exploring the success of trainees in obtaining competency in peripheral vascular access at an academic suburban ED with 120,000 annual visits. Eligible participants included healthcare workers that enrolled in the Operation STICK vascular access program and perform vascular access procedures as an aspect of their clinical practice. Competency in vascular access included both traditional and ultrasound-guided (US) peripheral intravenous catheter (PIVC) insertions. Competency was defined as demonstration of successful insertion of one traditional and one US PIVC in compliance with checklist. The primary objective was competency. Secondary objectives included trainee time to competency, trainee number of line encounters, and changes in program competency achievements over time. From October 15, 2021, to April 15, 2023, 141 clinicians participated in peripheral vascular access training via the Operation STICK model, which included 72 (51.1%) nurses, 52 (36.9%) ED technicians, and 17 (12.0%) healthcare personnel with other medical training. Clinicians overall reported an average of 5.6 years of experience inserting peripheral intravenous catheters (PIVCs) and 23 (16.3%) had experience with using ultrasound. About 122 (86.5%) clinicians successfully completed the program and demonstrated competency in traditional and ultrasound-guided techniques. Time to competency varied over time, with a median of 124 days in the early phase, 32.5 days middle phase, and 10.6 h over 9.5 days in the later phase of the program (p < 0.001). Achieving competency in PIVC insertion necessitates a focused effort on refining and systematizing education and training approaches. Recognizing the inherent challenges present in ED settings, it is feasible to effectively and efficiently train emergency clinicians to be expert in both basic and advanced PIVC placement techniques through participation in a well-organized vascular access training program.

A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial.

Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. The impact of education and training on vascular access outcomes in this vulnerable population is unclear. We aim to demonstrate the success of a program (Operation (O) STICK) on improving vascular access outcomes in DIVA patients. This was a quasi-experimental pre-post interventional study conducted at a tertiary care emergency department (ED) with 120,000 annual visits and 1100 hospital beds. Adult patients requiring an ultrasound-guided (US) peripheral intravenous catheter (PIVC) in the ED were eligible participants. Traditional (palpation method) insertions were excluded. Using multivariable linear regression and inverse probability weighted (IPW) linear regression, the standard group inclusive of PIVCs inserted by staff without formalized OSTICK training were compared to the interventional group inclusive of PIVCs inserted by staff with training and competency in the OSTICK training model. Data were collected over two time intervals: 4/1/21-9/30/21 (pre; non-OSTICK) and 10/1/22-3/31/23 (post; OSTICK). 2375 DIVA patients included 1035 (43.6%) non-OSTICK and 1340 (56.4%) OSTICK PIVCs. Overall, OSTICK PIVCs had a higher proportion of upper arm or forearm placements (94.6% vs 57.4%; p < 0.001), 20 gauge catheters (97.1% vs 92.3%; p < 0.001), and left-sided placements (54.4% vs 43.5%; p < 0.001). 62.7% of OSTICK PIVCs were placed by ED technicians, compared to 25.5% in the non-OSTICK group (p < 0.001). OSTICK PIVCs were placed on the first attempt 86.2% of the time and by the second attempt 95.4% of the time. In a subanalysis of 1343 hospitalized patients (689 (51.3%) OSTICK vs 654 (48.7%) non-OSTICK), OSTICK PIVCs survived for a median of 92% of the patient's hospital length of stay, compared to non-OSTICK PIVCs at 74% (p < 0.001). Formalized vascular access training in the ED leads to improved adherence to best practices for PIVC insertion, high success of cannulation with minimal attempts, and improved PIVC functionality during hospitalization for DIVA patients. Importantly, these outcomes are sustainable as they were captured 12 months after implementation of the program.

Bridging the Gap in Traditional PIVC Placement: An Evaluation of Operation STICK Vascular Access Outcomes.

Education and training is core to improving peripheral intravenous access outcomes. This study aimed to show that a vascular access training program (Operation STICK) in the emergency department (ED) improves the outcomes of traditionally placed peripheral intravenous catheters (PIVC). This was a pre-post quasi-experimental study of traditionally placed PIVCs at a large ED in southeastern Michigan, United States. A control group (non-OSTICK) was compared to an experimental group (OSTICK) using a 3:1 propensity score matched analysis. Groups were comprised of ED patients with traditional PIVC placements in two separate six-month periods: non-OSTICK PIVCs from April to September 2021 and OSTICK PIVCs (placed by an OSTICK graduate) from October 2022 to March 2023. The primary outcome was PIVC functionality. The secondary outcome was adherence to best practices. A total of 6512 PIVCs were included in the study; 4884 (75.0%) were in the non-OSTICK group, while 1628 (25.0%) were in the OSTICK group. 68.1% of OSTICK PIVCs and 59.7% of non-OSTICK PIVCs were placed by ED technicians (p < 0.001). 91.3% of OSTICK PIVCs were placed on the first attempt, and 98.5% were placed within two attempts. A subgroup analysis of admitted patients (2540 PIVCs; 553 (21.8%) OSTICK-trained and 1987 (78.2%) non-OSTICK-trained) revealed 87.6% of OSTICK PIVCs and 80.3% of non-OSTICK PIVCs were 20 gauge (p < 0.001). The median proportion of dwell time to hospital length of stay was 94% for OSTICK PIVCs, compared to 88% for non-OSTICK PIVCs (p < 0.001). This study underscores the value of education and training in enhancing vascular access outcomes. Implementing Operation STICK, a comprehensive vascular access training program, at a large ED has led to high first-stick success, adherence to best practice recommendations for site and device selection, and improved PIVC functionality for traditionally placed catheters.

Virtual Rural Trauma Team Development Course: Trying to Zoom in on a Solution.

The COVID-19 pandemic prevented centers from providing in-person interactive training programs such as the Rural Trauma Team Development Course. Adapting the course to a virtual platform is an option, yet little is known regarding the feasibility of using this format. This study aimed to evaluate the feasibility of providing a virtual rural trauma development course during COVID-19. This is a descriptive study of emergency medical technicians, nurses, emergency department technicians, and physicians from four rural community health care facilities and local emergency medical services who participated in a virtual Rural Trauma Team Development Course held in November 2021 which was transformed into a virtual platform using live remote interactive lectures, recorded case-based scenarios, and interactive virtual-based questions. The course was evaluated by the changes instituted at the centers based on program recommendations and a participant survey. A total of 41 participants were studied, of whom 31 (75%) returned the emailed postprogram survey. The majority (>75%) of respondents rated the activity as very good, with course objectives met. All four facilities instituted changes following the program, including enhancing policy and procedures, guidelines, advancing performance improvement triggers, and equipment acquisition. Individual-reported participant satisfaction was very high. The Rural Trauma Team Development Course can be provided virtually and is a feasible option for trauma centers to provide initial trauma management in the rural community in a safe pandemic-restrictive atmosphere.

Rethinking Traditional Emergency Department Care Models in a Post-Coronavirus Disease-2019 World

As the nursing shortage in United States emergency departments has drastically worsened since the coronavirus disease-2019 (COVID-19) pandemic, emergency departments have experienced increased rates of inpatient onboarding, higher rates of patients leaving without being seen, and declining patient satisfaction scores. This paper reviews the impacts of the coronavirus disease-2019 pandemic on the current nursing shortage and considers how various medical personnel (emergency nurse-extenders) can ameliorate operational challenges by redesigning emergency department systems. During the height of the coronavirus disease-2019 pandemic, the psychological effects of increased demand for emergency nurses coupled with the fear of coronavirus infection exacerbated nursing turnover rates. Health care workers who can be trained to augment the existing emergency department workforce include paramedics, Emergency Medical Technicians, emergency department technicians, ancillary staff, scribes, and motivated health sciences students. Utilizing non-nurse providers to fulfill tasks traditionally assigned to emergency nurses can improve emergency department flow and care delivery in a post-coronavirus disease-2019 world.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

Trauma Resuscitation Room Organization Using 5S Methodology: A Quality Improvement Initiative.

Trauma centers are required to have immediate availability of resources to stabilize traumatic injuries. However, maintaining trauma room organization can be challenging in the fast turnaround environment of trauma care. Implementation of 5S methodology has shown success in standardizing processes to maintain organized, efficient workspaces. The purpose of this study was to assess the implementation of 5S methodology on trauma resuscitation room organization, efficiency, and cost-effectiveness. This quality improvement pre- and postintervention study assessed the impact of 5S methodology on trauma resuscitation room organization. A 20-question survey was developed and administered to emergency department technicians before and after a multiphase intervention that included strategies for room reorganization, improved signage, creation of workstations, education, and implementation of a log sheet system. A final cost analysis was evaluated upon completion. Emergency department technicians completed n = 26 presurveys and n = 19 postsurveys. Room organization improved from preintervention 31% to postintervention 89%. Restocking with a checklist improved from 46% preintervention to 63% postintervention. A cost analysis summary identified 130 overstocked items equaling a total cost savings of $4,026.82. The 5S methodology improved trauma bay organization by sorting, organizing, standardizing, labeling, and color coding resuscitation supplies based on the ABCDE (airway, breathing, circulation, disability, and exposure) of the primary survey. Additional strategies included improved signage, workspace reorganization, staff education, and checklist restocking accountability. The 5S implementation resulted in significant cost savings.

Can Non-Physician Providers Use Ultrasound to Aid in Establishing Peripheral IV Access in Patients Who are Difficult to Cannulate? A Scoping Review.

Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate. Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate. A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians. Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.

Improving Emergency Department Airway Preparedness in the Era of COVID-19: An Interprofessional, In Situ Simulation.

The target audience for this airway simulation includes all emergency department (ED) staff who are potential members of a COVID-19 intubation team, including emergency medicine attendings, emergency medicine residents, nurses, respiratory therapists, pharmacists, and ED technicians. As of May 7, 2020 there were 1,219,066 diagnosed cases of COVID-19 in the U.S. and 73,297 deaths.1 A special report from the Centers for Disease Control and prevention on infections in healthcare personnel reported 9,282 cases between February 12th and April 9th.2 Sars-CoV-2 is a novel virus that requires a careful, coordinated approach to airway management given the high risk of aerosolization.3 It is essential to train ED staff (1) to appropriately care for patients with suspected COVID-19 disease and (2) to provide an organized, safe working environment for providers during high-risk, aerosolizing procedures such as intubation. In addition to providing a set of airway management guidelines, we aimed to educate the staff through participation in a simulation activity. Due to the multiple team members involved and the array of equipment needed, an in-person in situ strategy was implemented. The goals of the simulation were to optimize patient care and minimize viral exposure to those involved during intubation. At the conclusion of the simulation session, learners will be able to: 1) Understand the need to notify team members of a planned COVID intubation including: physician, respiratory therapist, pharmacist, nurse(s), and ED technician. 2) Distinguish between in-room and out-of-room personnel during high-risk aerosolizing procedures. 3) Distinguish between in-room and out-of-room equipment during high-risk aerosolizing procedures to minimize contamination. 4) Appropriately select oxygenation therapies and avoid high-risk aerosolizing procedures. 5) Manage high risk scenarios such as hypotension or failed intubation and be prepared to give push-dose vasoactive medications or place a rescue device such as an I-gel ®. This is a high-fidelity, interprofessional, in-situ simulation used to train a team of providers that would normally participate in the management of a patient with suspected COVID-19 requiring endotracheal intubation. Participants might include emergency medicine attendings, emergency medicine residents, nurses, respiratory therapists, pharmacists, and ED technicians. The patient is best represented by a high-fidelity mannequin such as Trauma HAL® (Miami, FL USA) https://www.gaumard.com/products/trauma/trauma-halr), with a monitor displaying vital signs and voice-response capabilities. The simulation includes an interprofessional debriefing session, during which an airway checklist, communication strategies, and best practices are reviewed. Airway management guidelines were developed by an interdisciplinary team at our institution. We used these guidelines from Stanford Health Care and best practices from a literature review to create a checklist of recommended steps. Two assessors used the checklist to track team actions. Any missed items were discussed in the team debrief and participants were encouraged to ask questions. At the end of the session, to check for understanding, participants were provided with a brief anonymous online survey accessed by a QR code. These assessments allowed the simulation team to iteratively edit the case before future simulations. From 3/23/20-4/23/20, we held 12 in-situ simulations with 62 participants, including emergency medicine physicians, nurses, technicians, respiratory therapists, and pharmacists. Two individuals observed each simulation and compared team performance to the checklist of recommended steps. The actions that were not completed during the simulation served as teaching points during the simulation debrief. The debrief discussions helped to identify misconceptions regarding oxygenation strategies, difficulties in staff communication due to physical barriers, and various other quality or safety concerns. Participant reactions following the simulation and debriefs were overwhelmingly positive. This simulation was an effective, easy-to-implement method of interprofessional team training for a risk-inherent procedure in the ED. We learned that the deliberate simulation of each step of the COVID19-specific intubation procedure with all team members provided opportunities to identify safety challenges in communication, equipment, and approach. Each debrief stimulated an excellent discussion among team members, and allowed for interprofessional feedback, clarification of questions, and recommendations for areas of improvement. Our main take-away from the pilot of this novel simulation case is that new, high-risk procedures require a coordinated team effort to minimize risks to patients and staff, and that team training is feasible and effective using frequent in situ simulations. Medical simulation, in-situ simulation, interprofessional, COVID-19, novel coronavirus, SARS-CoV-2, intubation, medical education, health professions education, team training, airway management.

Utility of the DIVA score for experienced emergency department technicians.

The DIVA score is validated for predicting success of the initial attempt at peripheral intravenous insertion by nurses and physicians. A score of 4 or greater is 50% to 60% likely to have a failed first attempt. The study objective was to assess the validity of this score for emergency department technicians. This study used a prospective convenience sample of 181 children presenting to the emergency department with intravenous access attempt by one of 29 emergency department technicians. DIVA score, total number of attempts, and median time to successful intravenous cannulation were obtained. Comparing patients with a DIVA score <4 to ≥4, first-time IV placement failure rates were lower (9% [95% CI, 3-24] vs. 41% [95% CI, 33-49]) and median time to IV placement was shorter (75 [interquartile range (IQR) 42-157] vs. 254 [IQR 91-806]) seconds. In patients with scores ≥4, emergency department technicians with ≥5 years of experience were significantly more likely to be successful on the first attempt (OR 2.8; 95% CI, 1.03-7.63). For every year of technician experience, the time to catheter placement, adjusted for DIVA score, decreased by 25 minutes (P≤0.05, R2=0.05). Comparing our receiver operating curve to the derivation study, the areas were similar (0.67 vs. 0.65). This study provides preliminary evidence for the validity of the DIVA score when applied to IVs placed by emergency department technicians. For patients with high DIVA scores, ≥5 years of IV experience was associated with higher odds of successful first-time IV placement and shorter time to placement. HIGHLIGHTS The difficult intravenous access (DIVA) score may be generalizable to IVs placed by experienced emergency department technicians (EDTs) Higher odds of first-time success in difficult patients with ≥5 years EDT experience Early identification of difficult access may allow for aid of alternative technology Likely first study to evaluate EDTs IV skills in patients with varying DIVA scores.

Implementation of a Novel Near Visual Acuity Chart in an Emergency Department Setting.

The quality of visual acuity (VA) measurement in emergency department (ED) settings can be affected by patient immobility and lack of standardized testing conditions. We implemented a previously validated, novel VA chart, the Runge Sloan letter near card, in a hospital ED and evaluated its impact on frequency and consistency of VA testing. Two hundred seventeen hospital ED ophthalmology consult records from December 1, 2016, to November 15, 2017, were evaluated in an IRB-approved protocol. Frequency of VA measurement and agreement between nonophthalmic ED technicians and ophthalmology physicians-in-training were assessed. Implementation of the Runge card saw missed technician VA evaluations decrease from 36% (43/120) to 21% (20/97) of ophthalmic consults (p = .01), without significant change in agreement of VA measurements. After implementation, the proportion of VA measurements differing between technicians and residents by ≤2 lines was 51%; with pinhole testing, it improved to 64% (p < .05). In patients with good VA of >20/80, pinhole increased agreement from 58% to 73% (p < .05). Implementation of the Runge card was associated with improved frequency of VA measurement and, when combined with pinhole testing, increased agreement rates. Our findings suggest utility of training in the use of the Runge card in ED settings.

Utility of the DIVA Score for Experienced Emergency Department Technicians

Highlights The DIVA score may be generalizable to IVs placed by experienced EDTs. Higher odds of first-time success in difficult patients with ≥5 years EDT experience. Early identification of difficult access may allow for aid of alternative technology. Likely first study to evaluate EDTs IV skills in patients with varying DIVA scores.

Multidisciplinary, In Situ Simulation Improves Experienced Caregiver Confidence With High-Risk Pediatric Emergencies.

Emergency department (ED) caregivers have reported feeling uncomfortable performing emergency pediatric procedures, likely because of either a lack of training or infrequent exposure to these events. To address these gaps, ongoing education for experienced ED caregivers must aim to improve caregiver confidence with high-risk, low-volume pediatric emergency care. This study used multidisciplinary, in situ simulations to facilitate improved caregiver confidence when treating pediatric emergencies in an ED setting. Two-hour pediatric code blue simulations were held in 7 EDs throughout the Seattle, Washington, metropolitan area. Questionnaire data were collected from 353 simulation participants (60% nurses, 19.5% ED technicians, 14% ED physicians; median team size = 5) via pre simulation and post simulation surveys assessing confidence and understanding regarding interventions/treatments, standard protocols, culture of safety behavior, and team members' roles/responsibilities. Paired t tests were used to analyze changes in self-reported confidence. Confidence improved across all questions (37%-57% of participants reported good/complete confidence pre simulation, improving 94%-98% post simulation; P < 0.00001 for all). Participants cited learning equipment location/use (37%), hands-on practice (32%), and discussion (22%) as the most helpful aspects of the simulations. Identified changes to practice made post simulation included more effective communication (18%) and utilization of a pediatric emergency drug sheet (13%). Multidisciplinary, in situ simulation improves experienced ED caregivers' confidence with pediatric emergencies in an ED setting. These findings suggest that investment in simulation-based education may improve clinical care and quality and safety improvement plans for the treatment of pediatric emergencies in general EDs.

Ultrasound-Guided Peripheral Intravenous Catheter Training Results in Physician-Level Success for Emergency Department Technicians.

To report our success and complication rates with emergency department (ED) technician-performed ultrasound (US)-guided peripheral intravenous (IV) catheter placement and to compare our results to similar studies in the literature. We conducted a retrospective review of a prospective database of patients who underwent US-guided peripheral IV catheter placement attempts for clinical care in the ED. All patients meeting difficult IV access criteria who had a US-guided peripheral IV catheter placement attempted by a trained ED technician were included. Average attempts per success and overall success rates were compared to similar published studies. There were 830 participants, with an overall success rate of ED technician- performed US-guided peripheral IV catheter placement of 97.5%. Clinicians categorized 82.6% of participants as having difficult IV access and reported that in 46.5%, a central venous catheter would have been necessary if the US-guided peripheral IV catheter failed. Of successful catheter attempts, 86.8% were placed on the first attempt; 11.6% were placed on the second attempt; and 1.6% were placed on the third attempt. For this study, the average number of attempts per success was 1.15 (95% confidence interval, 1.12-1.18), which was lower than in 6 other published studies, ranging from 1.27 to 1.70. The overall success rate of our ED technician-performed attempts was 0.970 (95% confidence interval, 0.956-0.983), which was higher than that reported in previous ED technician studies (0.79-0.80), and closer to that reported for physicians or nurses (0.87-0.97). The arterial puncture complication rate was 0.8%, which was also lower than in other published studies (1.25%-9.80%). With brief but comprehensive training, ED technicians can successfully obtain US-guided peripheral IV catheter access in patients with difficult IV access.

Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial

Randomized controlled trials report inconsistent findings when comparing the initial success rate of peripheral intravenous cannulation using landmark versus ultrasonography for patients with difficult venous access. We sought to determine which method is superior for patients with varying levels of intravenous access difficulty. We conducted a 2-group, parallel, randomized, controlled trial and randomly allocated 1,189 adult emergency department (ED) patients to landmark or ultrasonography, stratified by difficulty of access and operator. ED technicians performed the peripheral intravenous cannulations. Before randomization, technicians classified subjects as difficult, moderately difficult, or easy access according to visible or palpable veins and perception of difficulty with a landmark approach. If the first attempt failed, we randomized subjects a second time. We compared the initial and second-attempt success rates by procedural approach and difficulty of intravenous access, using a generalized linear mixed regression model, adjusted for operator. The 33 participating technicians enrolled a median of 26 subjects (interquartile range 9 to 55). The initial success rate was 81% but varied significantly by technique and difficulty of access. The initial success rate by ultrasonography was higher than landmark for patients with difficult access (48.0 more successes per 100 tries; 95% confidence interval [CI] 35.6 to 60.3) or moderately difficult access (10. 2 more successes per 100 tries; 95% CI 1.7 to 18.7). Among patients with easy access, landmark yielded a higher success rate (10.6 more successes per 100 tries; 95% CI 5.8 to 15.4). The pattern of second-attempt success rates was similar. Ultrasonographic peripheral intravenous cannulation is advantageous among patients with difficult or moderately difficult intravenous access but is disadvantageous among patients anticipated to have easy access.

151 Ultrasound-Guided Peripheral Intravenous Access by Emergency Department Technicians is a Safe and Effective Strategy for Avoiding Unnecessary Central Venous Catheters

151 Ultrasound-Guided Peripheral Intravenous Access by Emergency Department Technicians is a Safe and Effective Strategy for Avoiding Unnecessary Central Venous Catheters

Increased rates of rapid point-of-care HIV testing using patient care technicians to perform tests in the ED

BackgroundVarious emergency department (ED) HIV testing models are reported in the literature but may not all be sustainable. We sought to determine whether changing an ED rapid HIV testing program from counselor‐based to ED technician‐based resulted in more testing. MethodsWe evaluated data from an ED rapid HIV testing program. Triage nurses offered testing to patients. In 2009, counselors performed rapid testing weekdays from 10:00 am to 6:00 pm. In 2010, ED technicians were trained to perform the test and replaced counselors. We compared the numbers of tests performed during the same 6-month periods in 2009 and 2010. Study personnel abstracted results through medical record review. ResultsA total of 241 oral tests were performed in 2009 compared with 1483 in 2010, representing slightly more than a 6-fold increase. In 2010, there was a steady increase in testing month by month. Incorporating patient volume, testing rates increased from 1.3% to 8.1%. Oral testing yielded no positive test results in 2009, but 7 individuals (0.47%) tested newly positive during the testing period of 2010. Of those with a documented CD4 count within 100 days of the positive result, 4 of 5 had CD4 counts less than 200. ConclusionsWe present a novel approach to HIV testing using existing staff within the ED. This new ED technician–based model led to large increases in rates of testing.

Ultrasound-Guided Peripheral Intravenous Access Program Is Associated With a Marked Reduction in Central Venous Catheter Use in Noncritically Ill Emergency Department Patients

We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program. We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.

154 Reduction of Central Venous Catheter Placement After an Emergency Department Technician-Performed Ultrasound-Guided Peripheral Vascular Access Program

Central venous catheter placement is used for patients with difficult peripheral vascular access as an alternative to a peripheral intravenous catheter (IV). Central venous catheter placement carries a higher risk compared to peripheral IVs. Ultrasound (US) can be used to place IVs in patients who previously would have required central venous catheter placement. To determine whether the implementation of an emergency department (ED) technician performed, ultrasound-guided IV protocol leads to the reduction of central venous catheter placement, and focuses the procedure to patients with higher acuity. A retrospective analysis of the electronic medical record of an urban ED with an emergency medicine residency training program was performed, to identify patients who received central venous catheterizations in the ED. The patients were divided into a period before (period 1) and after (period 2) the implementation of a program in which ED technicians were trained to perform ultrasound-guided IV placement in patients with poor peripheral vascular access. The primary outcome was the incidence of central venous catheter placement, calculated before and after implementation of the program. Secondary outcomes included the changes in Emergency Severity Index (ESI) and disposition of patients who received central venous catheterization in the ED before and after the program, and the number of patients who received central venous catheterization and subsequently were discharged home at the completion of their treatment in the ED. In the years 2006-2010, a total of 1448 central venous catheterization procedures were performed in a single site teaching hospital with annual census growing from 60,239 in 2006 to 71,431 in 2010. We excluded patients who received central venous catheter in the year 2008 as this was the year that the program was piloted and fully implemented. A significant reduction in the total number of central venous catheter placements was observed from 848 in the first period, to 358 central venous catheters in the second period, representing a 58% central venous catheter reduction despite a 15.7% increase in ED census. (p<0.0001) There was a 41% increased risk of admission to the ICU and operating room among patients who had central venous catheter placement in the second period compared to first period (OR = 2.04; 95% CI, 1.67-2.50). In the period before program implementation, 10.6% of patients who received central venous catheters were discharged home, compared to 1.6% in the second period (OR = 0.15; 95% CI, 0.06-0.36). The implementation of an ED technician-performed ultrasound-guided peripheral IV protocol was associated with a reduction in central venous catheterization utilization. In addition, after the protocol, central venous catheterizations were more frequently placed in higher-acuity patients compared to before the protocol, as demonstrated by a higher risk of admission to the ICU/OR and a decrease in use of central venous catheterizations in patients ultimately discharged home from the ED.

Commentary: Emerging Crash Avoidance Technology: What Does It Mean to My ED?

Commentary: Emerging Crash Avoidance Technology: What Does It Mean to My ED?