Hrev_master [page 132] [Emergency Care Journal 2020; 16:9205] Emergency Care Journal 2020; volume 16:9205 Abstract Over a billion Peripheral Intra-Venous Cannulas (PIVC) are used globally every year with at least 25 million sold annually in the UK.1,2 The NHS spends an estimated £29m of its annual acute sector budget on PIVC procurement3 and around 70% of all hospi- talised patients require at least one PIVC during their stay.4 Despite their extensive and routine use, PIVC failure rates are reported as high as 50-69%.5-7 In addition, many PIVCs remain unused follow- ing insertion, particularly in the Emergency Department (ED).8,9 The risk factors for PIVC failure are not well understood and the literature has found extensive regional variation in practice when it comes to PIVC insertion and management.1,7,10 While various tech- nologies have been developed to address these issues, there remains a need for standardised, evidence-based guidelines. Introduction We conducted a semi-structured healthcare questionnaire sur- vey in the Royal Infirmary of Edinburgh ED which aimed to eval- uate the failure rate of PIVCs inserted pre-hospital and in the ED and identify factors associated with failure. Failure was defined as loss of PIVC function due to extravasation, phlebitis or occlusion. Cannula, patient, inserter and location data were collected over a 6-week period. It was also noted whether each PIVC had been doc- umented on the Electronic Patient Record (EPR) system, which contains a questionnaire template to be completed following PIVC insertion. Patients were followed up daily for the duration of their hospital stay. In the event of cannula removal, the reason was recorded in addition to the duration of PIVC survival. Data collec- tion was carried out on weekdays between the hours of 8am to 6pm. Patients were approached and invited to enrol in the study, after which data was captured in a standardised manner using a data and questionnaire sheet (see appendix). All patients were assigned anonymous identification numbers stored on a password protected drive and all patient data was anonymised prior to NHS release. This service evaluation survey was deemed by the South- East Scotland Research Ethics Service (SESRES) not to require formal ethics review and was registered with the Edinburgh Quality Improvement Projects in the ED (eQuIPED) registry. Pearson’s Chi-squared test was used to compare factors associated with PIVC failure and log-rank tests to compare factors associated with PIVC survival. Statistical analysis was conducted using IBM SPSS® Statistics version 24.0. Data were collected on a convenience sample of 104 patients with 119 PIVCs between 27.01.20 and 06.03.20. 90 PIVCs (75.6%) were inserted in the ED and 29 (24.4%) were inserted pre- hospital. Nurses inserted the largest proportion of PIVCs (n=49, 41.2%), followed by doctors (n=35, 29.4%), paramedics (n=29, 24.4%), physician associates (n=4, 3.4%) and medical students (n=2, 1.7%). The antecubital fossa was the most common insertion site (n=62, 52.1%) followed by the posterior hand (n=27, 22.7%), wrist (n=15, 12.6%), forearm (n=13, 10.9%), upper arm (n=1, 0.8%) and finger (n=1, 0.8%). 61 PIVCs (51.3%) were inserted in the non-dominant arm, with 58 (48.7%) in the dominant arm. Preferred PIVC gauge was 20G (n=78, 65.5%), followed by 18G (n=28, 23.5%), 22G (n=9, 7.6%) and 16G (n=4, 3.4%). Only 26 PIVCs (21.8%) were documented on the EPR system. Thirty-three PIVCs (27.7%) failed, with 15 (12.6%) routinely removed or no longer required and 13 (10.9%) removed for unde- fined reasons. In patients admitted, 29 PIVCs (42.6%) failed, with 15 (22.1%) removed routinely and 11 (16.2%) undefined. PIVC failure was associated with dominant arm insertion (p=0.011) and pre-hospital insertion (p=0.001). Log-rank tests revealed that cumulative PIVC survival was lower in dominant arm (p=0.01) and pre-hospital insertions (p<0.001). Kaplan-Meier curves are shown in Figure 1. Conclusions In conclusion, we found a high PIVC failure rate (43%) in admitted patients. Dominant arm and pre-hospital insertion were significantly associated with PIVC failure and this is consistent with previous research.6 Based on these results, we would suggest Correspondence: Adam Stanley, College of Medicine and Veterinary Medicine, 49 Little France Crescent, EH16 4SB, Edinburgh, UK Tel: 07568534509 E-mail: adamkstanley.edin@gmail.com Key words: Peripheral intravenous cannula, failure rate, emergency department. Conflict of interest: No one. This work was not supported by any grant. Ethics approval and consent to participate: The manuscript does not contain any elements that would allow the recognition of the patient. Ethics Commitment: The study was deemed by the South-East Scotland Regional Ethics Committee to be a service evaluation survey and did not therefore require formal ethical approval. Received for publication: 23 June 2020. Accepted for publication: 15 September 2020. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2020 Licensee PAGEPress, Italy Emergency Care Journal 2020; 16:9205 doi:10.4081/ecj.2020.9205 Peripheral Intravenous Cannula Usage in the Emergency Department Adam K Stanley,1 Ashton Barnett-Vanes,1,2 Matthew J Reed1,2 1College of Medicine and Veterinary Medicine, University of Edinburgh; 2Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK Non -co mmerc ial us e o nly [Emergency Care Journal 2020; 16:9205] [page 133] that dominant arm insertion should be avoided where possible. Pre-hospital insertion should only be undertaken if deemed neces- sary rather than routine, whilst acknowledging that patients are often undifferentiated and at high risk of deterioration, meaning a lower threshold for PIVC insertion is not unreasonably common practice. While guidance suggests that PIVCs should last at least 3 to 4 days if clean and not infected, our results show earlier drops in PIVC survival. The largest drop was observed on day 2, by which time patients had all been transferred to the Acute Medical Unit and/or downstream wards. Further research is needed to investigate PIVC management on the wards and the effects of patient transfer on PIVC survival. PIVC failure was not signifi- cantly associated with admission to any specific downstream ward or specialty. However, we were unable to determine whether spe- cific pathologies amongst patients contributed towards PIVC fail- ure. Therefore, further research investigating the relationship between disease and PIVC survival would be useful. Overall, our findings highlight the prominence of PIVC failure and together with other published research can begin to inform the development of standardised guidelines, essential to control the extensive varia- tion in practice and high PIVC failure rates. References 1. Alexandrou E, Ray-Barruel G, Carr PJ, Frost S, Inwood S, Higgins N, et al. International prevalence of the use of periph- eral intravenous catheters. J Hosp Med 2015;10:530-3. 2. NHS Clinical Evaluation Team. Clinical review: safety periph- eral intravenous cannula. 2018. Available from: https://www- media.supplychain.nhs.uk/media/Clinical_Review_Safety_Per ipheral_Intravenous_Cannula_Report_October_2018.pdf Accessed on: January 2020. 3. Guerrero MA. National evaluation of safety peripheral intra- venous catheters in a clinician-led project. Br J Nurs 2019;28:S29-32. 4. Webster J, Clarke S, Paterson D, et al. Routine care of periph- eral intravenous catheters versus clinically indicated replace- ment: randomised controlled trial. BMJ 2008;337:a339. 5. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but Unacceptable. J Infus Nurs 2015;38:189-203. 6. Marsh N, Webster J, Larsen E, Cooke M, Mihala G, Rickard CM. Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure. J Hosp Med 2018;13:83-9. 7. Alexandrou E, Ray-Barruel G, Carr PJ, et al. Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide. J Hosp Med. 2018 May 30;13. 8. Limm EI, Fang X, Dendle C, Stuart RL, Egerton Warburton D. Half of All Peripheral Intravenous Lines in an Australian Tertiary Emergency Department Are Unused: Pain with No Gain? Ann Emerg Med. 2013;62:521-5. 9. Gledstone-Brown L, McHugh D. Review article: Idle ‘just-in- case’ peripheral intravenous cannulas in the emergency depart- ment: Is something wrong? Emerg Med Australas. 2018;30: 309-26. 10. Webster J, Osborne S, Rickard C, Marsh N. Clinically-indicat- ed replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Syst Rev 2019. doi:10.1002/14651858.CD007798.pub5 Brief Report Figure 1. PIVC Kaplan-Meier survival curves by insertion arm (a) and procedure location (b). Non -co mmerc ial us e o nly