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• W2079790828 abstract "As emergency physicians, we like to intervene. Journal articles focus on new drug treatments, investigations or management. Many medical researchers are both motivated by the desire to discover a new treatment, and/or are encouraged to do so by drug and equipment manufacturers providing vitally needed funding. This, together with risk aversion and increasing expectations, has resulted in a potential cascade of over-investigation, diagnosis and treatment. Yet the need to ‘just do something’ may lead to patient harm. Researchers far less often investigate not doing something, or challenge currently accepted practice. Investigations or procedures performed in our ED – particularly by junior staff – are often a reflex action, or copy-cat behaviour, rather than based on sound understanding of whether the patient or healthcare system is likely to benefit. ED patients rarely question the need for a procedure or treatment, because of a lack of specialist knowledge, innate trust, anxiety about their condition, the stressful nature of the environment or the power imbalance. A recent paper published in Annals of Emergency Medicine by Limm et al. determined that 50% of peripheral i.v. catheters (PIVCs) inserted in adult patients in an Australian tertiary ED were unused.1 The study also demonstrated that 45% of patients admitted to the ward with an unused ED PIVC remained unused at 72 h post-admission. Thus, this procedure of unnecessary i.v. cannula insertion is putting patients at risk, without any significant chances of benefit. Some of the unused PIVC may have been justifiable at the time; however, this is likely to remain a minority. Although this research was performed in a single institution, it is probable that this same practice is occurring both nationally and internationally. PIVCs are a cause of significant discomfort for patients and put them at risk for infection and other complications. They also pose a small but real risk to the healthcare worker because of occupational exposure to bloodborne disease. A paper published recently by Stuart et al. in the Medical Journal of Australia demonstrated that almost a quarter of healthcare-associated Staphylococcus aureus bacteraemias (SABs) were associated with PIVCs.2 Almost 40% of these PIVC-associated SABs in this study were from i.v. cannulae inserted in the ED. The higher risk for PIVC SAB in both the pre-hospital (21% of SAB cases in the Stuart et al. study) and ED services compared with the inpatient setting has been demonstrated previously.3, 4 Unused PIVC also represents a non-value-added burden to already overstretched healthcare costs. Equipment and staff time, although individually small, become considerable over the healthcare system by their sheer volume. Direct costs have not been published, but the indirect costs of a single episode of PIVC-associated SAB have been re-calculated to be $29 500 in today's costs.2 The large majority of patients with an otherwise unused PIVC in the Limm et al. study had blood drawn for pathology tests.1 Authors have challenged the usefulness of many pathology tests ordered in the ED, suggesting that they do not all contribute to patient care, and add unproductive costs.5 This phenomenon could be described as the ‘heroic search for abnormal test results’. Efforts to reduce PIVC-associated complications, particularly SAB, have largely focused on insertion using a no touch sterile technique (aseptic no touch technique), line maintenance and line replacement.6-8 The insertion technique and cannula maintenance are regarded as the most important of these issues.6 The ED should take careful stewardship of how and when PIVCs are inserted to ensure they are done so in a safe manner, and only when really needed. The alternative is to remove PIVCs and replace them in the inpatient setting within 24 h, which places an unreasonable impost on both the patient and healthcare system. The exception would be the PIVC placed in the immediately life-threatening or resuscitation setting, when inserted using a non-sterile or less sterile technique, which clearly should be replaced once the clinical urgency allows. Although insertion technique aimed at minimising infective complications is paramount for the ED to address, we should also reconsider the need for our PIVCs in the first place. The safest, least resource-intensive and completely painless PIVC would be the one that was never inserted! With half the PIVC inserted remaining unused, this would suggest that many should never have been placed at all. When considering attempts to reduce PIVC SAB, not placing the catheter in the first place has seldom been addressed.6-8 This approach would address the root cause of the problem with ease and at no cost. Like most procedures, the decision to insert a PIVC or not should be discussed not only with a senior clinician, but more importantly with the patient. It is an opportunity for the patient to be involved in shared decision making, particularly in the case of the ‘just in case cannula’, or when alternate routes of fluid and drug administration are a clear option, such as oral fluid hydration with an antiemetic in children. Efforts should now be made to monitor and reduce excessive rates of unused PIVC in each ED. Quality improvement projects have been demonstrated to be effective in reducing rates of unused PIVC in the inpatient setting.9 The ED is often found to be the start of a cascade of potentially unnecessary events from practical procedures and over-investigation, to over-diagnosis and over-treatment. At best, these may be inconvenient and costly, and at worst they might actually be harming our patients.2 The ED is therefore in the ideal position to prevent harm. ‘Not doing stuff’ is hard for an ED doctor – like the counter-intuitive nature of leaning out from the mountainside while skiing downhill. Unfortunately, much positive reinforcement occurs in medical systems over prodigious test ordering and performing procedures, particularly for patients who are referred to inpatient units, where a long list of tests and differential diagnoses, however unlikely, are considered impressive and learned. We believe that inserting a PIVC using an aseptic technique that minimises risk for the patient, and only placing a cannula that is absolutely needed, should become a measured standard of ED care. None declared." @default.
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• W2079790828 date "2013-08-01" @default.
• W2079790828 modified "2023-10-04" @default.
• W2079790828 title "First do no harm: In fact, first do nothing, at least not a cannula" @default.
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