IV access difficulty: incidence and delays in an urban emergency department

Background: Intravenous access difficulty (IVAD) has long been recognized as a problem for emergency departments (ED), but epidemiologic data are lacking.

Objective: To estimate the incidence of IVAD and its associated delays in an urban ED.

Methods: We conducted this prospective cohort study in an urban ED at an academic medical center, enrolling adult patients who were likely to require an IV line. We recorded patients' history of IVAD and the time from the initial skin puncture to IV line establishment, noting the need for a second provider and the type of provider who was successful. We defined IVAD as follows: none, requiring a single skin puncture; mild, requiring multiple skin punctures; moderate, requiring a second non-physician provider; and severe, requiring a physician. We used descriptive statistics and calculated the relative risk (and 95% confidence interval [CI]) for the association between prior IVAD and observed moderate or severe IVAD.

Results: We enrolled 125 patients, 107 of whom had an IV line placed in the ED. Their median age was 48 (interquartile range 38-60) years. The incidence and median delays associated with IVAD categories were as follows: none, 61%/1 min; mild, 11%/5 min; moderate, 23%/15 min; and severe, 5%/120 min. Prior IVAD was associated with a 2.5-fold greater risk of observed IVAD (95% CI 1.3-4.7).

Conclusion: In an urban, tertiary care ED, mild and moderate IVAD was common and led to mild delays, but severe IVAD, requiring a physician, caused substantial delays.