The economic burden of difficult intravenous access in the emergency department from a United States’ provider perspective

Abstract

Background:

Peripheral intravenous catheter placement is one of the most common invasive procedures that nurses will perform, especially in emergency departments.

Aims:

This early analysis aimed to quantify the economic burden associated with intravenous therapy in patients presenting in emergency departments with difficult intravenous access, receiving traditional peripheral intravenous catheters. This may inform the opportunity for improvement for investment in nursing tools and services regarding difficult venous access burden reduction.

Methods:

Model parameter data were obtained from published literature where possible via a targeted literature review for the terms including relative variations of ‘Difficult Venous Access’, ‘burden’, and ‘costs’, or elicited from expert clinical opinion. A simple decision tree model was developed in Microsoft® Excel 2016. Results included number of insertion attempts, number of patients requiring escalation, catheter failures due to complications, healthcare professional (e.g. nurse) time, and total costs (including/excluding health care professional time). Sensitivity analyses were performed.

Results:

The model considers 64,000 individuals presenting in the emergency department annually, of which 75% (48,000) require a peripheral intravenous catheter; of these 22% (10,560) are estimated to have difficult venous access. The total cost burden of difficult venous access is estimated to be $890,095 per year/$84.29 per patient with difficult venous access, including the cost of clinician time. Key total cost drivers include the population size treated in the emergency department annually, the proportion of midlines placed by a specialist IV (intravenous access) nurse and the percentage of patients with difficult venous access.

Conclusion:

This is the first formal analysis estimating the significant economic burden of difficult venous access in emergency departments via peripheral intravenous catheter placement, a task frequently performed by nurses. Further studies are needed to evaluate nursing-centric strategies for reducing this burden. Additionally, adoption of a concise definition is needed, as is routine use of reliable assessment tools so that future cost analyses can be better contextualised.

Introduction

Peripheral intravenous catheters (PIVC) are used for short term vascular access to deliver intravenous (IV) medications and/or fluids to the patient and may also be used to draw blood samples (The Royal Childrens Hospital Melbourne, 2018). The insertion of a PIVC is required for up to 90% of patients during their hospital stay (Helm et al., 2015), and it is estimated that more than one billion PIVCs are inserted globally each year (Alexandrou et al., 2018). In North America alone, approximately 435.6 million PIVCs were sold in 2021 (iDATA Research Inc, 2020).

PIVC placement is one of the most common invasive procedures that nurses perform in the emergency department (ED) (Carr et al., 2016). In this setting, their timely insertion is vital for the evaluation and stabilisation of critically ill patients (Bahl et al., 2016). Cultural pressure on nurses to try without help until they achieve access has been described, as has the importance of training method (Ravik et al., 2017). If the first attempt to place a PIVC is unsuccessful, there are both clinical and economic implications.

The patient may experience significant pain and increased anxiety (Sou et al., 2017); there may be delays in diagnostic testing and subsequent treatment. Multiple insertion attempts can also lead to partial or total loss of the prescribed dose of medication, which could lead to an increase in a patient’s length of stay (Armenteros-Yeguas et al., 2017).

Beyond first attempt failures, venous depletion can occur (i.e. multiple insertion attempts can lead to progressive vascular degradation making subsequent attempts more difficult, compromising possible access sites). This can result in escalation to more invasive catheters (Pitts and Ostroff, 2019), such as midlines, acute central venous catheters (ACVCs) and peripherally inserted central catheters (PICCs). These catheters are more costly and can be associated with greater healthcare resource use and cost, with insertion performed by an IV specialist or physician, or in interventional radiology (IR; Deutsch et al., 2014; Sou et al., 2017).

Complications associated with multiple insertion attempts, and sub-optimal placement of PIVCs, include an increased risk of phlebitis, thrombosis and catheter-related infection, all of which increase the risk of premature device failure (Sou et al., 2017). The overall rate of PIVC failure is between 35% and 50% (Helm et al., 2015). Following PIVC failure, the risk of failure of each subsequent PIVC is increased (Hadaway, 2012). As with multiple insertion attempts, repeated PIVC failure can lead to venous depletion and its associated sequalae, as well as the need to treat minor or severe PIVC failure-related sequelae (Helm et al., 2015). The failure of PIVCs, along with the related complications results in increased and costlier resource use (Helm et al., 2015).

Individuals with difficult intravenous access (DIVA) represent approximately 22% of all PIVC insertions (Witting, 2012). These individuals can have non-visible and non-palpable veins, which complicates catheter insertion, and may necessitate the use of technological aids such as vein visualisation devices and PIVCs with an integrated guidewire (Guillon et al., 2015; Idemoto et al., 2014; Monteiro et al., 2021; Sebbane et al., 2013). Though DIVA is a term that is commonly used, it is not clearly defined. A recent systematic literature review (SLR) proposed an evidence-driven definition, where DIVA is assumed ‘when a clinician has two or more failed attempts at peripheral IV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins) or the patient has a stated or documented history of DIVA’ (Bahl et al., 2021).

Whilst DIVA is recognised as highly burdensome, a formal quantification of the economic burden has not been reported in the literature. The aim of this early analysis was to quantify the economic burden associated with the placement of PIVCs in patients presenting in the ED with DIVA. The analysis was performed to characterise current practice and the scope for cost-savings, against which other technologies or interventions may be compared in later-stage economic evaluations. This approach is in line with the iterative framework of economic evaluation advocated by Sculpher et al. (1997).

Methods

Model structure

A simple decision tree model was developed in Microsoft® Excel 2016 (Figure 1). A probability of insertion (stick) failure was assigned for patients based on the number of modelled insertion attempts, where higher attempts correlates with higher failure. Following stick failure, the decision tree allowed for escalations that could include a comprised midline, ACVC or PICC. In patients in whom PIVC insertion was successful, there was a probability of subsequent catheter failure due to complications.

Figure 1.

Model schematic, patient event and logic flow of economic burden of difficult venous access model.

PIVC, peripheral intravenous catheter.

Costs included in the analysis were PIVCs costs, (including the catheter, start kit and consumables), escalation catheters (midline, ACVC, PICC) costs, and the healthcare professional (HCP) labour time taken for catheter insertion.

Data

Model parameter data were obtained from published literature where possible via targeted literature review using PubMed for the terms including relative variations of ‘Difficult Venous Access’, ‘burden’ and ‘costs’. Table 1 indicates the literature values used as inputs and the reference citation. Where parameter values could not be identified from the literature, expert opinion was elicited. This was obtained via email correspondence and a follow-up telephone interview with an emergency medicine physician, who is a director at a large Vascular Access Network in the United States (US) and on the Board of Directors for the Association for Vascular Access Foundation (Bahl, 2021). The key inputs and data sources are presented in Table 1.

Table 1.

Key inputs and data sources, economic model for burden of difficult venous access.

Input	Default value	Reference
Patient population
Number of patients seen in the ED annually	64,000	Jeffery et al. (2020); midpoint of the range cited in the publication
% ED patients requiring a PIVC	75%	Helm et al. (2015); midpoint of the range cited in the publication
% PIVC patients with DIVA	22%	Witting (2012); percentage of patients with failed second attempt to establish IV access
Unit costs per DIVA patient
PIVC
Unit cost of conventional PIVC	$1.38	Tian (2018)
Start kit	$0.99	Smith (2020)
Consumables	$3.14 ‡	Morrell (2020)
PIVC replacement	$5.51	Assumed to be equal to the total cost of PIVC insertion
Escalation catheters (unit cost)
MST or traditional midline	$87.00	Deutsch et al. (2014)
ACVC	$94.80	Tian (2018)
PICC	$94.20	Tian (2018)
HCP cost per hour
Nurse	$43.00	KPMG (2017)
Specialist IV nurse	$43.00	KPMG (2017); assumed to be equal to nurse hourly cost
Physician	$105.22	U.S. Bureau of Labor and Statistics (2020)
Cost per procedure
Interventional radiology	$1500	Deutsch et al. (2014)
Insertion attempts per patient
Nurse	2.2	Expert opinion
Specialist IV nurse	2.0	Expert opinion
Clinical data
Proportion of patients requiring escalation	20%	Expert opinion
Proportion of escalated patients receiving *
MST or traditional midline	71.4%	Expert opinion
ACVC	14.3%	Expert opinion
PICC	14.3%	Expert opinion
Catheter failure rate due to complications	43%	Helm et al. (2015); midpoint of the range cited in the publication
Labour
Minutes to place
Traditional PIVC	15.8	Bahl et al. (2016)
MST or traditional midline	35.0	Expert opinion
ACVC	45.0	Expert opinion
PICC	45.0	Expert opinion
Proportion of catheters placed by nurse
MST or traditional midline	10.0%	Expert opinion
ACVC	5.0%	Expert opinion
PICC	1.0%	Expert opinion
Proportion of catheters placed by specialist IV nurse
MST or traditional midline	85.0%	Expert opinion
ACVC	10.0%	Expert opinion
PICC	84.0%	Expert opinion
Proportion of catheters placed by physician
MST or traditional midline	2.5%	Expert opinion
ACVC	80.0%	Expert opinion
PICC	0%	Expert opinion
Proportion of catheters placed in interventional radiology
MST or traditional midline	2.5%	Expert opinion
ACVC	5.0%	Expert opinion
PICC	15.0%	Expert opinion

ACVC: acute central venous catheter; ED: emergency department; DIVA: difficult intravenous access; HCP: healthcare professional; IV: intravenous; MST: modified Seldinger technique; PICC: peripherally inserted central catheter; PIVC: peripheral intravenous catheter; US: United States.

^*Morrell (2020) reported a cost of $5.51 per short peripheral catheter (SPC) start kit, which included catheter cost, start kit cost and consumable cost. However, disaggregated costs were not published. The consumables cost of $3.14 was therefore derived by subtracting the cost of a traditional PIVC ($1.38 (Tian, 2018)) and start kit ($0.99 (Smith, 2020)) from the $5.51 cost per SPC start kit reported by Morrell (2020).

^‡To calculate the proportion of escalated patients receiving each type of catheter, values provided by the clinical expert for the percentage of all patients receiving a PIVC were re-weighted to total 100%. The weighted values were then applied to the percentage of escalated patients. The clinical expert confirmed that these values represented a reasonable breakdown in the escalated patients.

Assumptions

In this analysis (simple decision tree, using Microsoft® Excel 2016), a patient is considered to have DIVA if any of the following elements are present: a clinician has ⩾2 failed attempts at peripheral IV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins), or the patient has a stated or documented history of DIVA (Bahl et al., 2021).

The cost of catheter failure was assumed to comprise the cost of repeat PIVC insertion, including the catheter, start kit and consumables.

A published cost per hour was not identified for a specialist IV nurse. As such, this cost was assumed to be equal to the cost per hour of base wages for a permanent, full-time nurse (KPMG, 2017).

Results of the analysis

The analysis estimates resource use and cost per patient, and total annual resource use and cost for an average ED from the US payer perspective. Results of the analysis include the total (per population with DIVA per year in an average ED and per patient with DIVA) number of insertion attempts, the number of patients requiring escalation, catheter failures due to complications, HCP time (hours), and total costs (including and excluding HCP time).

Included sensitivity analysis

Univariate and probabilistic sensitivity analyses (PSA) were performed on total annual cost (Microsoft® Excel 2016), in which all base case parameter values were varied across their plausible range. Where a plausible range was not available for a parameter, the base case value was varied between ±25%. Ranges used in sensitivity analysis are provided in Supplemental Table 1. In univariate analysis, each model input was varied individually between the minimum and maximum plausible value, and the impact on the total annual cost assessed. In PSA all model inputs were randomly sampled from their underlying distributions at the same time and the impact on the total annual cost assessed.

Results

Base case analysis

The model considers a hospital with 64,000 individuals presenting in ED annually, of which 75% (48,000) require a PIVC. Of these, 22% (10,560) are estimated to have DIVA. Therefore, the base case analysis considers a population of 10,560 eligible patients with DIVA. Model results are presented per patient and per population.

The number of insertion attempts, patients requiring escalation and catheter failures per year estimated by the model are presented in Table 2, along with the estimated number of HCP hours required to insert catheters including multiple PIVC insertion attempts and the insertion of escalation catheters.

Table 2.

Difficult venous access events and healthcare provider labour time (hours) used in difficult venous access burden model.

Decision tree event and HCP time	Mean per patient	Total per population per year
Decision tree event
Insertion attempts	5.6	59,432
Escalation to advanced line	0.2	2,112
Catheter failures	0.3	3,590
HCP time (hours)
Nurse	0.2	2,053
Specialist IV nurse	0.3	2,735
Physician	0.02	203

HCP, healthcare professional; IV, intravenous.

The estimated annual costs associated with DIVA, including, and excluding the costs of HCP time, are presented in Table 3.

Table 3.

Estimated annual costs associated with difficult venous access in the emergency department.

Outcomes	Annual cost ($)
	Mean per patient (95% CI)	Total per population per year (95% CI)
PIVC	23.14 (23.08–23.18)	244,380 (242,863–246,320)
Escalation	17.83 (17.80–17.87)	188,270 (187,354–190,011)
Catheter failures	7.87 (7.84–7.88)	83,089 (82,605–83,843)
HCP labour cost	35.45 (35.23–35.83)	374,356 (372,335–381,070)
Total cost excluding HCP labour	48.84 (48.72–48.87)	515,738 (512,961–520,035
Total cost including HCP labour	84.29 (84.04–84.67)	890,095 (886,184–900,216)

CI: confidence interval; DIVA: difficult intravenous access; HCP: healthcare professional; PIVC: peripheral intravenous catheter.

Sensitivity analysis

Univariate sensitivity analysis

Figure 2 and Table 4 show the model inputs having the greatest individual impact on the total annual cost of DIVA in patients presenting in the ED, including the cost of HCP time. The tornado diagram in Figure 2 shows the effect of varying each input at a time, while keeping all other inputs at their base case value. The vertical line shows the base case estimate of total annual cost of DIVA patients in the ED ($890,095). The horizontal bars show the impact on this outcome when each input is varied between its lowest and highest plausible value (Figure 2). The total annual cost at the lowest and highest plausible value for each parameter is also shown in Table 4.

Figure 2.

Tornado diagram, magnitude of effect of inputs in difficult venous access burden model on economic burden outcomes.

The highest and lowest plausible value for each parameter is presented in parentheses.

ACVC: acute central venous catheter; ED: emergency department; DIVA: difficult intravenous access; IV: intravenous; PICC: peripherally inserted central catheter; PIVC: peripheral intravenous catheter; pts: patients.

Table 4.

Impact on total cost of patients with difficult venous access presenting in the emergency department per year from low and high input range values (sensitivity analysis).

Outcomes	At lower value of the parameter ($)	At upper value of the parameter ($)
Base case = $890,095
Number of patients seen in the ED (annually)	180,800	1,599,389
% of midlines placed by specialist IV nurse	1,362,911	556,342
% PIVC patients with DIVA	606,883	1,335,142
% ED patients requiring a PIVC	712,076	1,068,114
% patients requiring escalation	797,230	982,960
% of ACVCs placed by a physician	975,847	804,342
% of PICCs placed by specialist IV nurse	983,091	819,240
Insertion attempts by a nurse	874,501	1,030,438
% patients requiring escalation having Midline	964,297	815,892

ACVC: acute central venous catheter; DIVA: difficult intravenous access; ED: emergency department; IV: intravenous; PICC: peripherally inserted central catheter; PIVC: peripheral intravenous catheter.

The most important drivers of total cost include the size of the population treated in the ED each year, the proportion of midlines placed by a specialist IV nurse and the prevalence of DIVA in patients requiring a PIVC. Due to difficulty identifying a cost per hour for a specialist IV nurse, this cost was set to be equal to the standard nurse cost per hour in this analysis. Consequently, the higher the proportion of escalation catheters placed by the specialist IV nurse, the lower the total cost of managing patients with DIVA.

Probabilistic sensitivity analysis

Table 5 shows the outputs of PSA. In PSA, the mean cost of managing patients with DIVA in an average ED was estimated to be $893,200 per year (95% CI $886,184–$900,216).

Table 5.

Outputs of the probabilistic sensitivity analysis for economic burden of difficult venous access model.

Inputs	Mean	Lower 95% CI	Upper 95% CI
No. of events
Insertion attempts	59,507	59,093	59,922
Patients requiring escalation	2115	2101	2130
Catheter failures	3594	3569	3618
Nurse hours	2035	2021	2050
Specialist IV nurse hours	2757	2738	2777
Physician hours	204	202	205
Costs ($)
PIVC	244,592	242,863	246,320
Escalation	188,682	187,354	190,011
Catheter failures	83,224	82,605	83,843
HCP time	376,702	372,335	381,070
Total cost	893,200	886,184	900,216

CI: confidence interval; HCP: healthcare professional; IV: intravenous; PIVC: peripheral intravenous catheter; PSA: probabilistic sensitivity analysis.

Discussion

DIVA is highly burdensome, leading to multiple failed PIVC insertion attempts, escalation to more expensive and invasive catheters, and catheter failures; it adds stress to one of the most challenging nursing task to learn (Ravik et al., 2017). This early analysis provides estimates of the significant healthcare resource use and cost implications.

The analysis considers a population of 64,000 patients per year in an ED based on an average annual ED volume from a retrospective, observational, cross-sectional study of 24 EDs in the US (Jeffery et al., 2020). Assuming 22% of patients have DIVA, the total cost burden is estimated to be around $890,095 for the population with DIVA per year and $84.29 per patient with DIVA, including the cost of HCP time.

Extrapolating the model results to the total number of ED visits in the US shows DIVA presents a substantial national economic burden. With 144.8 million ED visits annually (Rubin, 2021), applying a 22% prevalence of DIVA, suggests there are around 31.9 million patients with DIVA presenting in the ED in the US each year. The estimated cost of DIVA in these patients would be expected to be around $2.68 billion (31.9 million × $84.29 per patient with DIVA).

This is the first formal analysis evaluating the cost burden of patients with DIVA in the ED. Previous studies have assessed the cost burden of multiple PIVC insertions among hospitalised patients but not necessarily in the cohort of patients with DIVA (Steere et al., 2019; van Loon et al., 2020). van Loon et al. (2020) reported that the cost of PIVC insertion increases with the number of failed insertion attempts. In the study by Steere et al. (2019), compared with standard practice, a five-step multimodal best practice intervention strategy was associated with significantly reduced overall costs, despite increased labour costs, supply costs and cost per placement. This was due to a marked reduction in the number of insertion attempts and catheters used per patient. These studies support the hypothesis that multiple failed insertion attempts present a significant economic burden.

Key drivers of the cost burden per patient in our early analysis were the percentage of patients with DIVA requiring escalation and the HCP placing midlines, ACVCs and PICCs. If a higher percentage of midlines, ACVCs and PICCs are placed by a nurse or specialist IV nurse, the cost is lower than if they are placed by a physician or in IR.

The overall economic burden is also dependent on the prevalence of DIVA, which is contingent on the method by which DIVA patients are identified. According to a recent SLR, the prevalence of DIVA is highly variable, ranging from 6% to 87.7% (Bahl et al., 2021). This reflects a lack of a consensus on the identification of patients with DIVA. Patients with DIVA are typically identified by a combination of methods including, but not limited to, failed attempts at PIV access using traditional techniques, physical examination findings such as lack of visible or palpable veins, and personal history of DIVA. Sensitivity analysis was conducted to assess the impact of varying DIVA prevalence on the overall economic burden. Based on 144.8 million ED admissions each year, the number of patients with DIVA could range from 8.7 million (based on a 6% prevalence) to around 127 million (based on a prevalence of 87.7%) with an associated cost of between approximately $733.3 million to $10.7 billion respectively.

A strength of this early study is that the analysis transparently considers the costs and resource consequences resulting from current patient management. While a formal definition of DIVA is lacking, this analysis is novel in that it attempts to identify the burden of multiple sticks within a cohort of patients with DIVA versus the general population, some of whom may suffer additional sticks due to reasons beyond vasculature status. The use of a formal approach to evaluate the economic burden of DIVA also means that uncertainty in model parameters has been assessed using univariate and probabilistic sensitivity analysis.

However, a limitation of this analysis relates to a paucity of data pertaining to the resource use and costs associated with DIVA, resulting in the need to elicit multiple parameter values from expert clinical opinion. Additionally, the lack of consensus relating to the definition of DIVA makes contextualisation to any given account with regards to cost implications challenging. Widespread adoption of a concise definition, and reliable assessment tools is needed before future cost assessments.

Expert opinion was taken to ensure the face validity of the data used; however, ideally all parameter values within the analysis would have been sourced from the published literature and preferably from large-scale, real-world evidence from the United States. There remains uncertainty in the values used in the analysis and there is a need for future research to generate more robust estimates of the key model parameters. Whilst parameter values were varied across a plausible range in sensitivity analysis, where data were unavailable for a parameter, this range was based on ±25% of the base case value. This is common practice in economic analysis of healthcare interventions but may not reflect the plausible range seen in clinical practice. In addition, in the base case analysis, parameter values taken from the literature were based on mean or median values. These values do not explicitly capture regional resource use and cost variations. For example, HCP salaries, that can vary from state to state in the United States.

This analysis is likely to be conservative, as it does not capture all aspects of the clinical and economic burden of DIVA due to a paucity of published data. Excluded costs include those associated with prolonged hospital stay in the ED, treating the complications leading to catheter failure (e.g. dislodgement, occlusion, phlebitis, thrombosis, or infection), complications associated with escalated catheters, and the potential for partial or total loss of the prescribed dose of medication. The model only accounts for the cost of replacing failed PIVCs, which is the most common approach regardless of complication severity. The time for placement of PICCs only includes the insertion time and does not consider the time to confirm tip location (the tip must be precisely positioned inside the patient, chest xray is one way to verify this) after initial placement, address malposition, or time in the IR unit for a chest X-ray after blind insertion. The analysis also excludes the clinical and economic implications of delays in diagnostic testing and subsequent treatment. Of these omissions, increased hospital stay is likely to be a significant driver of cost as DIVA has been shown to be an independent predictor of prolonged hospital stay in the ED (Shokoohi et al., 2020).

The model also excludes any potential financial implications associated with poor patient experience resulting from multiple PIVC insertion attempts. For example, via the merit-based incentive payments system.

The inclusion of patients with a stated or documented history of DIVA in the model may affect the estimated number of patients with DIVA. Several studies cite that history of multiple insertion attempts or history of DIVA is a strong predictor of difficult venous access (Armenteros-Yeguas et al., 2017; Monteiro et al., 2021). Specifically, Monteiro et al. (2021) found that adults with a history of DIVA were four times more likely to have DIVA. Including this population helps to accurately reflect the true number of patients with DIVA. However, as history of difficult venous access may be attributable to clinical status, which will vary from one encounter to the next, this may result in an over-estimate of the number of patients with DIVA.

Finally, the impact of the economic burden of DIVA and multiple PIVC insertion attempts from the patient’s perspective (i.e. the impact on patient’s financial responsibility) is not considered within the US provider perspective of the current analysis, but it is likely to be significant.

Further research is required to evaluate the economic impact of assessing patients for DIVA prior to the first insertion attempt and taking action to avoid multiple insertion attempts in these patients. Adoption of a standardised definition would be a helpful first step. Clinical guidelines and standards, such as the Infusion Nurses Society (INS) 2021 (Gorski et al., 2021) and the Australian Commission on Safety and Quality in Healthcare (Australian Commission on Safety and Quality in Health Care, 2019), have recently started providing recommendations for patients with DIVA. However, guidelines recommending specific tools for DIVA assessment, with a standard definition of DIVA, are lacking. Research such as this analysis could inform future clinical guidelines based on a better understanding of the relative resource use and costs involved with the assessment of and proactive intervention in patients presenting with DIVA in the ED.

Conclusion

This is the first analysis quantifying the economic burden of DIVA on the ED in hospitals. Nurses bear much of the responsibility for PIVC placement and thus this burden. Despite being unable to capture all of the clinical and economic consequences of DIVA, due to a paucity of data, this early analysis shows that DIVA is costly. The substantial economic burden highlights the urgent need to consider nursing-centric strategies to reduce the burden of DIVA.

Key points for policy, practice and/or research

• PIVC placement in the ED is the most common nurse-led invasive task, and DIVA patients contribute to its challenge.

• Although difficult intravenous access (DIVA) is recognised as highly burdensome, a formal quantification of the economic burden of DIVA has not been reported in the literature.

• This early analysis aimed to quantify the economic burden associated with the placement of peripheral intravenous catheters in patients presenting in the emergency department with DIVA, in order to characterise current practice and the scope for cost-savings, against which other technologies or interventions may be compared in later-stage economic evaluations.

• Despite being unable to capture all clinical and economic consequences of DIVA, due to a paucity of data, this early analysis shows that DIVA is associated with substantial costs.

• There is an urgent need for further studies which evaluate potential nursing-centric strategies for reducing the burden of DIVA.

Biography

Smeet Gala, MS, BTech has expertise in health economics and outcomes research. She holds an MS in Pharmacy Administration from St. John’s University, a B.Tech in Pharmaceutical Sciences from Institute of Chemical Technology, and is currently an Associate Director of Health Economics and Outcomes Research at BD.

Kim Alsbrooks, RN, started her career as a Radiologic Technologist and then Registered Nurse. She has 20 years of expertise in vascular access and evidence generation. She is currently a Senior Director of Medical Affairs for BD.

Amit Bahl, MD MPH is a board-certified Emergency Medicine physician with subspecialty expertise in emergency ultrasound. He is the Division Head of Emergency Ultrasound and Programme Director of the Emergency Ultrasound Fellowship programme at Corewell Health William Beaumont University Hospital in Southeastern Michigan. His academic appointment is Associate Professor of Emergency Medicine at Oakland University William Beaumont School of Medicine.

Megan Wimmer, MBA, BSci has expertise in health economics and outcomes research. She holds an MBA from Carnegie Mellon University’s Tepper School of Business, a BS in Microbiology and Biochemistry, and is currently a Director of Health Economics and Outcomes Research at BD.